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Kurup R, Wijeysundera HC, Bagur R, Ybarra LF. Complete Versus Incomplete Percutaneous Coronary Intervention-Mediated Revascularization in Patients With Chronic Coronary Syndromes. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2023; 47:86-92. [PMID: 36266152 DOI: 10.1016/j.carrev.2022.10.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2022] [Revised: 09/26/2022] [Accepted: 10/10/2022] [Indexed: 01/25/2023]
Abstract
Multivessel coronary artery disease (CAD) is associated with worse outcomes across the spectrum of clinical presentations. The prognostic implications of completeness of revascularization in CAD patients, especially those with chronic coronary syndromes (CCS), remain highly debated. This is largely due to the use of non-standardized definitions for complete revascularization (CR) and incomplete revascularization (ICR) within previously published studies, lack of randomized clinical data, varying revascularization methods and heterogenous study populations. In particular, the utility and effectiveness of PCI-mediated CR for CCS remains unknown. In this review, we discuss the various definitions used for CR vs. ICR, highlight the rationale for pursuing CR and summarise the current literature regarding the effects of PCI-mediated CR on clinical outcomes in patients with CCS.
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Affiliation(s)
- Rahul Kurup
- Chronic Total Occlusion Program, London Health Sciences Centre, Division of Cardiology, Department of Medicine, Schulich School of Medicine & Dentistry, Western University, London, ON, Canada
| | | | - Rodrigo Bagur
- Chronic Total Occlusion Program, London Health Sciences Centre, Division of Cardiology, Department of Medicine, Schulich School of Medicine & Dentistry, Western University, London, ON, Canada
| | - Luiz F Ybarra
- Chronic Total Occlusion Program, London Health Sciences Centre, Division of Cardiology, Department of Medicine, Schulich School of Medicine & Dentistry, Western University, London, ON, Canada.
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Mavromatis K, Boden WE, Maron DJ, Mancini GBJ, Weintraub WS, Gosselin G, Berman DS, Shaw LJ, Spertus JA, Hochman JS. Comparison of Outcomes of Invasive or Conservative Management of Chronic Coronary Disease in Four Randomized Controlled Trials. Am J Cardiol 2022; 185:18-28. [PMID: 36257844 DOI: 10.1016/j.amjcard.2022.09.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2022] [Revised: 08/17/2022] [Accepted: 09/09/2022] [Indexed: 01/09/2023]
Abstract
Revascularization and medical therapy for chronic coronary disease have both evolved significantly over the last 50 years. A total of 4 contemporary randomized controlled trials- Clinical Outcomes Utilizing Revascularization and Aggressive drug Evaluation (COURAGE), Bypass Angioplasty Revascularization Investigation 2 Diabetes (BARI 2D), Fractional Flow Reserve versus Angiography for Multivessel Evaluation 2 (FAME 2), and International Study of Comparative Health Effectiveness with Medical and Invasive Approaches (ISCHEMIA)-have assessed the incremental benefit of revascularization when added to secondary prevention with intensive pharmacologic and lifestyle intervention. We reviewed these 4 seminal studies with the objective of marshaling evidence to better frame how these results should apply to clinical decision making. These studies differed in study design, end points, intensity of treatment, and revascularization techniques. Nevertheless, they all demonstrate similar rates of "hard" clinical events with invasive and conservative management, and varying degrees of benefit in angina-related quality of life with revascularization. In conclusion, although controversy persists concerning the role of revascularization because of differing interpretations of the clinical trial evidence, we contend that instead of being competing management strategies, invasive and conservative approaches are complementary.
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Affiliation(s)
- Kreton Mavromatis
- Division of Cardiology, Atlanta VA Health Care System, Atlanta, Georgia; Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia.
| | - William E Boden
- Department of Medicine, VA New England Healthcare System, Boston University School of Medicine, Boston, Massachusetts
| | - David J Maron
- Stanford Prevention Research Center, Division of Cardiovascular Medicine, Department of Medicine, Stanford University School of Medicine, Stanford, California
| | - G B John Mancini
- Department of Medicine, Division of Cardiology, Center for Cardiovascular Innovation, University of British Columbia, Vancouver, British Columbia, Canada
| | - William S Weintraub
- MedStar Health and Department of Medicine, MedStar Health Research Institute, Georgetown University, Washington, District of Columbia
| | - Gilbert Gosselin
- Department of Medicine, Montreal Heart Institute, Montreal, Québec, Canada
| | - Daniel S Berman
- Division of Cardiology, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, California
| | - Leslee J Shaw
- Icahn School of Medicine at Mt Sinai, New York, New York
| | - John A Spertus
- Department of Medicine, Saint Luke's Mid America Heart Institute, University of Missouri - Kansas City, Kansas City, Missouri
| | - Judith S Hochman
- Division of Cardiology, Department of Medicine, New York University Grossman School of Medicine, New York, New York
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Smilowitz NR, Carey EP, Shah B, Hartigan PM, Plomondon ME, Maron DJ, Maddox TM, Spertus JA, Mancini GBJ, Chaitman BR, Weintraub WS, Sedlis SP, Boden WE. Comparison of Characteristics and Outcomes of Veterans With Stable Ischemic Heart Disease Enrolled in the COURAGE Trial Versus the Veterans Affairs Clinical Assessment, Reporting, and Tracking Program. Am J Cardiol 2022; 180:1-9. [PMID: 35918234 PMCID: PMC10019948 DOI: 10.1016/j.amjcard.2022.06.049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2022] [Revised: 06/19/2022] [Accepted: 06/22/2022] [Indexed: 11/29/2022]
Abstract
Randomized clinical trials have not demonstrated a survival benefit with percutaneous coronary intervention in stable ischemic heart disease (SIHD). We evaluated the generalizability of the COURAGE (Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation) trial findings to the broader population of veterans with SIHD. Veterans who underwent coronary angiography between 2005 and 2013 for SIHD were identified from the Veterans Affairs Clinical Assessment, Reporting and Tracking Program (VA CART). Patient-level comparisons were made between patients from VA CART who met the eligibility criteria for COURAGE and veterans enrolled in COURAGE between 1999 and 2004. All-cause mortality over long-term follow-up was assessed using Cox proportional hazards models. COURAGE-eligible patients from VA CART (n = 59,758) were older, had a higher body mass index, a greater prevalence of co-morbidities, but fewer diseased vessels on index coronary angiography, and were less likely to be on optimal medical therapy at baseline and on 1-year follow-up compared with VA COURAGE participants (n = 968). Patients from VA CART (median follow-up 6.5 years) had higher all-cause mortality (adjusted hazard ratio [aHR] 1.98 [1.61 to 2.43]) than participants from VA COURAGE (median follow-up: 4.6 years). Risks of mortality were greater in the 56.4% patients from CART who were medically managed (aHR 1.94 [1.49 to 2.53]) and in the 43.6% who underwent percutaneous coronary intervention (aHR 1.99 [1.45 to 2.74]), compared with their respective VA COURAGE arms. In conclusion, in this noncontemporaneous patient-level analysis, veterans in the randomized COURAGE trial had more favorable outcomes than the population of veterans with SIHD at large.
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Affiliation(s)
- Nathaniel R Smilowitz
- Cardiology Section, Department of Medicine, VA New York Healthcare Network, New York, New York; Division of Cardiology, Department of Medicine, NYU School of Medicine, New York, New York
| | - Evan P Carey
- Rocky Mountain Regional VA Medical Center, Aurora, Colorado
| | - Binita Shah
- Cardiology Section, Department of Medicine, VA New York Healthcare Network, New York, New York; Division of Cardiology, Department of Medicine, NYU School of Medicine, New York, New York.
| | | | - Mary E Plomondon
- CART Program, Office of Quality and Patient Safety, Veterans Health Administration, Washington, District of Columbia
| | - David J Maron
- Stanford University School of Medicine, Stanford, California
| | - Thomas M Maddox
- Division of Cardiology, Washington University School of Medicine, St. Louis, Missouri
| | - John A Spertus
- Mid-America Heart Institute, University of Missouri, Kansas City, Kansas City, Missouri
| | - G B John Mancini
- Centre for Cardiovascular Innovation, Vancouver Hospital, Vancouver, British Canada, Canada
| | | | - William S Weintraub
- MedStar Health Research Institute, Georgetown University, Washington, District of Columbia
| | - Steven P Sedlis
- Cardiology Section, Department of Medicine, VA New York Healthcare Network, New York, New York; Division of Cardiology, Department of Medicine, NYU School of Medicine, New York, New York
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Jafary FH, Jafary AH. Ischemia Trial: Does the Cardiology Community Need to Pivot or Continue Current Practices? Curr Cardiol Rep 2022; 24:1059-1068. [PMID: 35653055 PMCID: PMC9161182 DOI: 10.1007/s11886-022-01725-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/19/2022] [Indexed: 11/30/2022]
Abstract
PURPOSE OF REVIEW For decades, the standard of care for stable ischemic heart disease (SIHD) has been an ischemia-centric approach based on largely observational data suggesting a survival benefit of revascularization in patients with moderate-or-severe ischemia. In this article, we will objectively review the evolution of the ischemia paradigm, the trial evidence comparing revascularization to medical therapy in SIHD, and what contemporary practice should be in 2022. RECENT FINDINGS Randomized trials, including COURAGE and, most recently, the ISCHEMIA trial, have shown no reduction in "hard outcomes" like death and myocardial infarction (MI) in SIHD compared to medical therapy. The trial excluded high-risk patients with left main disease, low ejection fraction (EF) < 35%, and severe unacceptable angina. Irrespective of the severity of ischemia and the extent of coronary artery disease (CAD), revascularization did not offer any prognostic advantage over medical therapy. On the other hand, there was a durable improvement in symptoms. While there are many caveats to the ISCHEMIA trial, the overall strengths of the trial outweigh these limitations. The findings of ISCHEMIA are consistent with previous trials. It is time for the cardiology community to pivot towards medical therapy as the initial step for most patients with SIHD. Physicians should have the "COURAGE" to embrace "ISCHEMIA" and be comfortable with treating ischemia medically.
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Affiliation(s)
- Fahim H Jafary
- Department of Cardiology NHG Heart Institute, Tan Tock Seng Hospital, 11 Jalan Tan Tock Seng, Singapore, 308433, Singapore.
| | - Ali H Jafary
- St. George's University School of Medicine, University Centre, St. George's, Grenada
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Akbari T, Al-Lamee R. Percutaneous coronary intervention in multi-vessel disease. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2022; 44:80-91. [DOI: 10.1016/j.carrev.2022.06.254] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Revised: 06/21/2022] [Accepted: 06/21/2022] [Indexed: 01/09/2023]
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Lopes RD, Alexander KP, Stevens SR, Reynolds HR, Stone GW, Pina IL, Rockhold FW, Elghamaz A, Lopez-Sendon JL, Farsky PS, Chernyavskiy AM, Diaz A, Phaneuf D, De Belder MA, Ma YT, Guzman LA, Khouri M, Sionis A, Hausenloy DJ, Doerr R, Selvanayagam JB, Maggioni AP, Hochman JS, Maron DJ. Initial Invasive Versus Conservative Management of Stable Ischemic Heart Disease in Patients With a History of Heart Failure or Left Ventricular Dysfunction: Insights From the ISCHEMIA Trial. Circulation 2020; 142:1725-1735. [PMID: 32862662 PMCID: PMC7703498 DOI: 10.1161/circulationaha.120.050304] [Citation(s) in RCA: 71] [Impact Index Per Article: 17.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2020] [Accepted: 08/19/2020] [Indexed: 02/05/2023]
Abstract
BACKGROUND Whether an initial invasive strategy in patients with stable ischemic heart disease and at least moderate ischemia improves outcomes in the setting of a history of heart failure (HF) or left ventricular dysfunction (LVD) when ejection fraction is ≥35% but <45% is unknown. METHODS Among 5179 participants randomized into ISCHEMIA (International Study of Comparative Health Effectiveness With Medical and Invasive Approaches), all of whom had left ventricular ejection fraction (LVEF) ≥35%, we compared cardiovascular outcomes by treatment strategy in participants with a history of HF/LVD at baseline versus those without HF/LVD. Median follow-up was 3.2 years. RESULTS There were 398 (7.7%) participants with HF/LVD at baseline, of whom 177 had HF/LVEF >45%, 28 HF/LVEF 35% to 45%, and 193 LVEF 35% to 45% but no history of HF. HF/LVD was associated with more comorbidities at baseline, particularly previous myocardial infarction, stroke, and hypertension. Compared with patients without HF/LVD, participants with HF/LVD were more likely to experience a primary outcome composite of cardiovascular death, nonfatal myocardial infarction, or hospitalization for unstable angina, HF, or resuscitated cardiac arrest (4-year cumulative incidence rate, 22.7% versus 13.8%; cardiovascular death or myocardial infarction, 19.7% versus 12.3%; and all-cause death or HF, 15.0% versus 6.9%). Participants with HF/LVD randomized to the invasive versus conservative strategy had a lower rate of the primary outcome (17.2% versus 29.3%; difference in 4-year event rate, -12.1% [95% CI, -22.6 to -1.6%]), whereas those without HF/LVD did not (13.0% versus 14.6%; difference in 4-year event rate, -1.6% [95% CI, -3.8% to 0.7%]; P interaction = 0.055). A similar differential effect was seen for the primary outcome, all-cause mortality, and cardiovascular mortality when invasive versus conservative strategy-associated outcomes were analyzed with LVEF as a continuous variable for patients with and without previous HF. CONCLUSIONS ISCHEMIA participants with stable ischemic heart disease and at least moderate ischemia with a history of HF or LVD were at increased risk for the primary outcome. In the small, high-risk subgroup with HF and LVEF 35% to 45%, an initial invasive approach was associated with better event-free survival. This result should be considered hypothesis-generating. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT01471522.
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Affiliation(s)
| | | | | | | | - Gregg W. Stone
- Icahn School of Medicine at Mount Sinai, Cardiovascular Research Foundation, New York NY, USA
| | - Ileana L. Pina
- Wayne State Univ/Central Michigan University, Detroit, MI, USA
| | | | - Ahmed Elghamaz
- Northwick Park Hospital-Royal Brompton Hospital, London, UK
| | | | | | - Alexander M. Chernyavskiy
- E. Meshalkin National medical research center of the Ministry of Health of the Russian Federation (E.Meshalkin NMRC), Russia
| | - Ariel Diaz
- CIUSSS-MCQ, University of Montreal, Campus Mauricie, Trois-Rivieres, Canada
| | | | | | - Yi-tong Ma
- First Affiliated Hospital of Xinjiang Medical University, Urumqi, Xinjiang, China
| | | | | | - Alessandro Sionis
- Intensive Cardiac Care Unit, Cardiology Department, Hospital de la Santa Creu i Sant Pau, IIB-Sant Pau, CIBER-CV, Universitat Autònoma de Barcelona, Spain
| | - Derek J. Hausenloy
- The Hatter Cardiovascular Institute, Institute of Cardiovascular Sciences, University College London, London, UK
- Cardiovascular & Metabolic Disorders Program, Duke-National University of Singapore Medical School, Singapore
- National Heart Research Institute Singapore, National Heart Centre, Singapore
- Yong Loo Lin School of Medicine, National University Singapore, Singapore
- Cardiovascular Research Center, College of Medical and Health Sciences, Asia University, Taiwan
| | - Rolf Doerr
- Praxisklinik Herz und Gefaesse, Dresden, Germany
| | | | | | | | - David J. Maron
- Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA
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Reynolds HR, Shaw LJ, Min JK, Spertus JA, Chaitman BR, Berman DS, Picard MH, Kwong RY, Bairey-Merz CN, Cyr DD, Lopes RD, Lopez-Sendon JL, Held C, Szwed H, Senior R, Gosselin G, Nair RG, Elghamaz A, Bockeria O, Chen J, Chernyavskiy AM, Bhargava B, Newman JD, Hinic SB, Jaroch J, Hoye A, Berger J, Boden WE, O’Brien SM, Maron DJ, Hochman JS. Association of Sex With Severity of Coronary Artery Disease, Ischemia, and Symptom Burden in Patients With Moderate or Severe Ischemia: Secondary Analysis of the ISCHEMIA Randomized Clinical Trial. JAMA Cardiol 2020; 5:773-786. [PMID: 32227128 PMCID: PMC7105951 DOI: 10.1001/jamacardio.2020.0822] [Citation(s) in RCA: 97] [Impact Index Per Article: 24.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2019] [Accepted: 02/28/2020] [Indexed: 12/18/2022]
Abstract
Importance While many features of stable ischemic heart disease vary by sex, differences in ischemia, coronary anatomy, and symptoms by sex have not been investigated among patients with moderate or severe ischemia. The enrolled ISCHEMIA trial cohort that underwent coronary computed tomographic angiography (CCTA) was required to have obstructive coronary artery disease (CAD) for randomization. Objective To describe sex differences in stress testing, CCTA findings, and symptoms in ISCHEMIA trial participants. Design, Setting, and Participants This secondary analysis of the multicenter ISCHEMIA randomized clinical trial analyzed baseline characteristics of patients with stable ischemic heart disease. Individuals were enrolled from July 2012 to January 2018 based on local reading of moderate or severe ischemia on a stress test, after which blinded CCTA was performed in most. Core laboratories reviewed stress tests and CCTAs. Participants with no obstructive CAD or with left main CAD of 50% or greater were excluded. Those who met eligibility criteria including CCTA (if performed) were randomized to a routine invasive or a conservative management strategy (N = 5179). Angina was assessed using the Seattle Angina Questionnaire. Analysis began October 1, 2018. Interventions CCTA and angina assessment. Main Outcomes and Measures Sex differences in stress test, CCTA findings, and symptom severity. Results Of 8518 patients enrolled, 6256 (77%) were men. Women were more likely to have no obstructive CAD (<50% stenosis in all vessels on CCTA) (353 of 1022 [34.4%] vs 378 of 3353 [11.3%]). Of individuals who were randomized, women had more angina at baseline than men (median [interquartile range] Seattle Angina Questionnaire Angina Frequency score: 80 [70-100] vs 90 [70-100]). Women had less severe ischemia on stress imaging (383 of 919 [41.7%] vs 1361 of 2972 [45.9%] with severe ischemia; 386 of 919 [42.0%] vs 1215 of 2972 [40.9%] with moderate ischemia; and 150 of 919 [16.4%] vs 394 of 2972 [13.3%] with mild or no ischemia). Ischemia was similar by sex on exercise tolerance testing. Women had less extensive CAD on CCTA (205 of 568 women [36%] vs 1142 of 2418 men [47%] with 3-vessel disease; 184 of 568 women [32%] vs 754 of 2418 men [31%] with 2-vessel disease; and 178 of 568 women [31%] vs 519 of 2418 men [22%] with 1-vessel disease). Female sex was independently associated with greater angina frequency (odds ratio, 1.41; 95% CI, 1.13-1.76). Conclusions and Relevance Women in the ISCHEMIA trial had more frequent angina, independent of less extensive CAD, and less severe ischemia than men. These findings reflect inherent sex differences in the complex relationships between angina, atherosclerosis, and ischemia that may have implications for testing and treatment of patients with suspected stable ischemic heart disease. Trial Registration ClinicalTrials.gov Identifier: NCT01471522.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | - Derek D. Cyr
- Duke Clinical Research Institute, Durham, North Carolina
| | | | | | | | - Hanna Szwed
- National Institute of Cardiology, Warsaw, Poland
| | - Roxy Senior
- Northwick Park Hospital-Royal Brompton Hospital, London, United Kingdom
| | | | | | - Ahmed Elghamaz
- Northwick Park Hospital-Royal Brompton Hospital, London, United Kingdom
| | - Olga Bockeria
- National Research Center for Cardiovascular Surgery, Moscow, Russia
| | - Jiyan Chen
- Guangdong General Hospital, Guangzhou, China
| | - Alexander M. Chernyavskiy
- E.Meshalkin National medical research center of the Ministry of Health of the Russian Federation (E.Meshalkin NMRC), Moscow, Russia
| | | | | | | | - Joanna Jaroch
- Wroclaw Medical University, T. Marciniak Hospital, Wroclaw, Poland
| | - Angela Hoye
- The University of Hull/Castle Hill Hospital, Cottingham, United Kingdom
| | | | | | | | - David J. Maron
- Department of Medicine, Stanford University, Stanford, California
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Weintraub WS, Hartigan PM, Mancini GBJ, Teo KK, Maron DJ, Spertus JA, Chaitman BR, Shaw LJ, Berman D, Boden WE. Effect of Coronary Anatomy and Myocardial Ischemia on Long-Term Survival in Patients with Stable Ischemic Heart Disease. Circ Cardiovasc Qual Outcomes 2020; 12:e005079. [PMID: 30773025 DOI: 10.1161/circoutcomes.118.005079] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Background The severity of coronary artery disease (CAD) and of ischemia are evaluated to guide therapy, but their relative prognostic importance remains uncertain. Accordingly, we sought to clarify their association with long-term survival in the COURAGE trial (Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation). Methods and Results Survival data from after the original trial period ended was obtained at 15 Veterans Affairs sites and 13 of 18 United States non-Veterans Affairs sites. Date of death was obtained from the Veterans Affairs system-wide Corporate Data Warehouse and the National Death Index. Of the original 2287 patients in COURAGE, 1370 (60%) had both stress perfusion imaging and quantitative coronary angiography available, with extended survival evaluated in 767 subjects. Survival was calculated by the Kaplan-Meier method, and a Cox proportional-hazards model adjusted for baseline differences. There were 369 all-cause deaths during a median follow-up of 7.9 years (range, 0-15 years). The number of coronary arteries diseased predicted survival (HR, 1.25; 95% CI, 1.09-1.43), whereas severity of ischemia did not (HR, 0.99; 95% CI, 0.80-1.22). Percutaneous coronary intervention did not offer a survival advantage over optimal medical therapy (HR, 0.95; 95% CI, 0.77-1.16) and there was no interaction between therapeutic strategy and number of coronary arteries diseased or severity of ischemia. In fully adjusted models, the number of coronary arteries diseased was not associated with increased mortality. Conclusions In univariate analysis, the number of coronary arteries diseased predicted long-term mortality, but severity of ischemia did not. Adjusted for baseline variables, neither assessment approach predicted mortality. Overall, there was no survival benefit from percutaneous coronary intervention in any subset defined by either angiographic or ischemic severity. Clinical Trial Registration: URL: https://www.clinicaltrials.gov . Unique identifier: NCT00007657.
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Affiliation(s)
- William S Weintraub
- MedStar Heart & Vascular Institute, Georgetown University, Washington, DC (W.S.W.)
| | | | - G B John Mancini
- Division of Cardiology, Department of Medicine, University of British Columbia, Vancouver, BC, Canada (G.B.J.M.)
| | - Koon K Teo
- Department of Medicine, McMaster University Medical Center, Hamilton, ON, Canada (K.K.T.)
| | - David J Maron
- Department of Medicine, Stanford University School of Medicine, CA (D.J.M.)
| | - John A Spertus
- Mid-America Heart Institute, and Department of Biomedical and Health Informatics, University of Missouri Kansas City (J.A.S.)
| | - Bernard R Chaitman
- Division of Cardiology, Department of Medicine, Saint Louis University School of Medicine, MO (B.R.C.)
| | - Leslee J Shaw
- Departments of Medicine and Radiology, Weill Cornell Medical Center, NY (L.J.S.)
| | - Daniel Berman
- Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, CA (D.B.)
| | - William E Boden
- Massachusetts Veterans Epidemiology, Research, and Informatics Center (MAVERIC), VA New England Healthcare System, and Division of Cardiovascular Medicine, Department of Medicine, Boston University School of Medicine (W.E.B.)
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9
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Trends in Death Rate 2009 to 2018 Following Percutaneous Coronary Intervention Stratified by Acuteness of Presentation. Am J Cardiol 2019; 124:1349-1356. [PMID: 31547993 DOI: 10.1016/j.amjcard.2019.07.059] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2019] [Revised: 07/24/2019] [Accepted: 07/25/2019] [Indexed: 11/23/2022]
Abstract
Percutaneous coronary intervention (PCI) has evolved dramatically, along with patient complexity. We studied trends in in-hospital mortality with changes in patient complexity over the last decade stratified by clinical presentation. The study population included all patients presenting to the cardiac catheterization lab between January 2009 and July 2018. Expected in-hospital mortality was calculated using the National Cardiovascular Data Registry CathPCI risk scoring system. Yearly mean in-hospital mortality rates (%) were plotted and smoothed by weighted least squares regression for each presentation: ST-elevation myocardial infarction (STEMI), non-ST-elevation acute coronary syndrome (NSTE-ACS), and stable ischemic coronary artery disease (SI CAD). The overall cohort included 13,732 patients who underwent PCI during the study period, of whom 2,142 were for STEMI, 2,836 for NSTE-ACS, and 8,754 for SI CAD. Indications for PCI have changed over time, with more PCIs being performed for NSTE-ACS and STEMI than for SI CAD. NSTE-ACS and STEMI patients had a steady decrease in in-hospital mortality over time compared with SI CAD patients. Overall observed mortality continues to decrease in NSTE-ACS patients, with reduction in the observed mortality rate within the STEMI population to below expected since 2013. Patient complexity has not changed significantly. These results may be attributed to improved patient selection coupled with optimal pharmacotherapy with more robust therapies during procedure and hospitalization.
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10
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Schulman-Marcus J, Lin FY, Gransar H, Berman D, Callister T, DeLago A, Hadamitzky M, Hausleiter J, Al-Mallah M, Budoff M, Kaufmann P, Achenbach S, Raff G, Chinnaiyan K, Cademartiri F, Maffei E, Villines T, Kim YJ, Leipsic J, Feuchtner G, Rubinshtein R, Pontone G, Andreini D, Marques H, Chang HJ, Chow BJW, Cury RC, Dunning A, Shaw L, Min JK. Coronary revascularization vs. medical therapy following coronary-computed tomographic angiography in patients with low-, intermediate- and high-risk coronary artery disease: results from the CONFIRM long-term registry. Eur Heart J Cardiovasc Imaging 2018; 18:841-848. [PMID: 28329294 PMCID: PMC5837582 DOI: 10.1093/ehjci/jew287] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2016] [Accepted: 01/24/2017] [Indexed: 01/10/2023] Open
Abstract
Aims To identify the effect of early revascularization on 5-year survival in patients with CAD diagnosed by coronary-computed tomographic angiography (CCTA). Methods and results We examined 5544 stable patients with suspected CAD undergoing CCTA who were followed a median of 5.5 years in a large international registry. Patients were categorized as having low-, intermediate-, or high-risk CAD based on CCTA findings. Two treatment groups were defined: early revascularization within 90 days of CCTA (n = 1171) and medical therapy (n = 4373). To account for the non-randomized referral to revascularization, we developed a propensity score by logistic regression. This score was incorporated into Cox proportional hazard models to calculate the effect of revascularization on all-cause mortality. Death occurred in 363 (6.6%) patients and was more frequent in medical therapy. In multivariable models, when compared with medical therapy, the mortality benefit of revascularization varied significantly over time and by CAD risk (P for interaction 0.04). In high-risk CAD, revascularization was significantly associated with lower mortality at 1 year (hazard ratio [HR] 0.22, 95% confidence interval [CI] 0.11–0.47) and 5 years (HR 0.31, 95% CI 0.18–0.54). For intermediate-risk CAD, revascularization was associated with reduced mortality at 1 year (HR 0.45, 95% CI 0.22–0.93) but not 5 years (HR 0.63, 95% CI 0.33–1.20). For low-risk CAD, there was no survival benefit at either time point. Conclusions Early revascularization was associated with reduced 1-year mortality in intermediate- and high-risk CAD detected by CCTA, but this association only persisted for 5-year mortality in high-risk CAD.
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Affiliation(s)
| | - Fay Y Lin
- Dalio Institute of Cardiovascular Imaging, Weill Cornell Medical College and New York Presbyterian Hospital, New York, NY, USA
| | - Heidi Gransar
- Department of Imaging, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Daniel Berman
- Department of Imaging, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Tracy Callister
- Tennessee Heart and Vascular Institute, Hendersonville, TN, USA
| | | | - Martin Hadamitzky
- Division of Cardiology, Deutsches Herzzentrum Munchen, Munich, Germany
| | - Joerg Hausleiter
- Division of Cardiology, Deutsches Herzzentrum Munchen, Munich, Germany
| | - Mouaz Al-Mallah
- King Saud Bin Abdul Aziz University for Health Sciences, King Abdullah International Medical Research Center, King Abdul Aziz Cardiac Center, Ministry of National Guard, Health Affairs, Saudi Arabia
| | - Matthew Budoff
- Department of Medicine, Harbor UCLA Medical Center, Los Angeles, CA, USA
| | | | | | | | - Kavitha Chinnaiyan
- Cardiovascular Imaging Unit, Giovanni XXIII Hospital, Monastier, Treviso, Italy
| | - Filippo Cademartiri
- Cardiovascular Imaging Unit, Giovanni XXIII Hospital, Monastier, Treviso, Italy
| | - Erica Maffei
- Cardiovascular Imaging Unit, Giovanni XXIII Hospital, Monastier, Treviso, Italy
| | - Todd Villines
- Department of Medicine, Walter Reed Medical Center, Washington, DC, USA
| | - Yong-Jin Kim
- Seoul National University Hospital, Seoul, South Korea
| | - Jonathon Leipsic
- Department of Medicine and Radiology, University of British Columbia, Vancouver, BC, Canada
| | - Gudrun Feuchtner
- Department of Radiology, Medical University of Innsbruck, Innsbruck, Austria
| | - Ronen Rubinshtein
- Department of Cardiology at the Lady Davis Carmel Medical Center, The Ruth and Bruce Rappaport School of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| | - Gianluca Pontone
- Department of Clinical Sciences and Community Health, University of Milan, Centro Cardiologico Monzino, IRCCS, Milan, Italy
| | - Daniele Andreini
- Department of Clinical Sciences and Community Health, University of Milan, Centro Cardiologico Monzino, IRCCS, Milan, Italy
| | - Hugo Marques
- Department of Surgery, Curry Cabral Hospital, Lisbon, Portugal
| | - Hyuk-Jae Chang
- Division of Cardiology, Severance Cardiovascular Hospital, Seoul, South Korea
| | - Benjamin J W Chow
- Department of Medicine and Radiology, University of Ottawa, ON, Canada
| | | | | | - Leslee Shaw
- Division of Cardiology, Emory University School of Medicine, Atlanta, GA, USA
| | - James K Min
- Dalio Institute of Cardiovascular Imaging, Weill Cornell Medical College and New York Presbyterian Hospital, New York, NY, USA
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11
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Affiliation(s)
- Joshua D Mitchell
- Cardiovascular Division, Washington University School of Medicine, St. Louis, MO
| | - David L Brown
- Cardiovascular Division, Washington University School of Medicine, St. Louis, MO
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Al-Mohaissen MA, Carere RG, Mancini GBJ, Humphries KH, Whalen BA, Lee T, Scheuermeyer FX, Ignaszewski AP. A Plaque Disruption Index Identifies Patients with Non-STE-Type 1 Myocardial Infarction within 24 Hours of Troponin Positivity. PLoS One 2016; 11:e0164315. [PMID: 27711184 PMCID: PMC5053518 DOI: 10.1371/journal.pone.0164315] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2016] [Accepted: 09/22/2016] [Indexed: 12/11/2022] Open
Abstract
Background Markers of plaque destabilization and disruption may have a role in identifying non-STE- type 1 Myocardial Infarction in patients presenting with troponin elevation. We hypothesized that a plaque disruption index (PDI) derived from multiple biomarkers and measured within 24 hours from the first detectable troponin in patients with acute non-STE- type 1 MI (NSTEMI-A) will confirm the diagnosis and identify these patients with higher specificity when compared to individual markers and coronary angiography. Methods We examined 4 biomarkers of plaque destabilization and disruption: myeloperoxidase (MPO), high-sensitivity interleukin-6, myeloid-related protein 8/14 (MRP8/14) and pregnancy-associated plasma protein-A (PAPP-A) in 83 consecutive patients in 4 groups: stable non-obstructive coronary artery disease (CAD), stable obstructive CAD, NSTEMI-A (enrolled within 24 hours of troponin positivity), and NSTEMI-L (Late presentation NSTEMI, enrolled beyond the 24 hour limit). The PDI was calculated and the patients’ coronary angiograms were reviewed for evidence of plaque disruption. The diagnostic performance of the PDI and angiography were compared. Results Compared to other biomarkers, MPO had the highest specificity (83%) for NSTEMI-A diagnosis (P<0.05). The PDI computed from PAPP-A, MRP8/14 and MPO was higher in NSTEMI-A patients compared to the other three groups (p<0.001) and had the highest diagnostic specificity (87%) with 79% sensitivity and 86% accuracy, which were higher compared to those obtained with MPO, but did not reach statistical significance (P>0.05 for all comparisons). The PDI had higher specificity and accuracy for NSTEMI-A diagnosis compared to coronary angiography (P<0.05). Conclusions A PDI measured within 24 hour of troponin positivity has potential to identify subjects with acute Non-ST-elevation type 1 MI. Additional evidence using other marker combinations and investigation in a sufficiently large non-selected cohort is warranted to establish the diagnostic accuracy of the PDI and its potential role in differentiating type 1 and type 2 MI in patients presenting with troponin elevation of uncertain etiology.
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Affiliation(s)
- Maha A. Al-Mohaissen
- Department of Clinical Sciences, Princess Nourah bint Abdulrahman University, Riyadh, Saudi Arabia
- * E-mail:
| | - Ronald G. Carere
- Department of Medicine, Division of Cardiology, St. Paul's Hospital and the University of British Columbia, Vancouver, BC, Canada
| | - G. B. John Mancini
- Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Karin H. Humphries
- Department of Medicine, Division of Cardiology, St. Paul's Hospital and the University of British Columbia, Vancouver, BC, Canada
| | - Beth A. Whalen
- Centre for Heart Lung Innovation, St. Paul's Hospital and University of British Columbia, Vancouver, BC, Canada
| | - Terry Lee
- Centre for Health Evaluation and Outcome Sciences, St. Paul’s Hospital and University of British Columbia, Vancouver, BC, Canada
| | - Frank X. Scheuermeyer
- Department of Emergency Medicine, St. Paul's Hospital and the University of British Columbia, Vancouver, BC, Canada
| | - Andrew P. Ignaszewski
- Department of Medicine, Division of Cardiology, St. Paul's Hospital and the University of British Columbia, Vancouver, BC, Canada
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13
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Weisz G, Généreux P, Iñiguez A, Zurakowski A, Shechter M, Alexander KP, Dressler O, Osmukhina A, James S, Ohman EM, Ben-Yehuda O, Farzaneh-Far R, Stone GW. Ranolazine in patients with incomplete revascularisation after percutaneous coronary intervention (RIVER-PCI): a multicentre, randomised, double-blind, placebo-controlled trial. Lancet 2016; 387:136-45. [PMID: 26474810 DOI: 10.1016/s0140-6736(15)00459-6] [Citation(s) in RCA: 76] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND Incomplete revascularisation is common after percutaneous coronary intervention and is associated with increased mortality and adverse cardiovascular events. We aimed to assess whether adjunctive anti-ischaemic pharmacotherapy with ranolazine would improve the prognosis of patients with incomplete revascularisation after percutaneous coronary intervention. METHODS We performed this multicentre, randomised, parallel-group, double-blind, placebo-controlled, event-driven trial at 245 centres in 15 countries in Europe, Israel, Russia, and the USA. Patients (aged ≥18 years) with a history of chronic angina with incomplete revascularisation after percutaneous coronary intervention (defined as one or more lesions with ≥50% diameter stenosis in a coronary artery ≥2 mm diameter) were randomly assigned (1:1), via an interactive web-based block randomisation system (block sizes of ten), to receive either twice-daily oral ranolazine 1000 mg or matching placebo. Randomisation was stratified by diabetes history (presence vs absence) and acute coronary syndrome presentation (acute coronary syndrome vs non-acute coronary syndrome). Study investigators, including all research teams, and patients were masked to treatment allocation. The primary endpoint was time to first occurrence of ischaemia-driven revascularisation or ischaemia-driven hospitalisation without revascularisation. Analysis was by intention to treat. This study is registered at ClinicalTrials.gov, number NCT01442038. FINDINGS Between Nov 3, 2011, and May 27, 2013, we randomly assigned 2651 patients to receive ranolazine (n=1332) or placebo (n=1319); 2604 (98%) patients comprised the full analysis set. After a median follow-up of 643 days (IQR 575-758), the composite primary endpoint occurred in 345 (26%) patients assigned to ranolazine and 364 (28%) patients assigned to placebo (hazard ratio 0·95, 95% CI 0·82-1·10; p=0·48). Incidence of ischaemia-driven revascularisation and ischaemia-driven hospitalisation did not differ significantly between groups. 189 (14%) patients in the ranolazine group and 137 (11%) patients in the placebo group discontinued study drug because of an adverse event (p=0·04). INTERPRETATION Ranolazine did not reduce the composite rate of ischaemia-driven revascularisation or hospitalisation without revascularisation in patients with a history of chronic angina who had incomplete revascularisation after percutaneous coronary intervention. Further studies are warranted to establish whether other treatment could be effective in improving the prognosis of high-risk patients in this population. FUNDING Gilead Sciences, Menarini.
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Affiliation(s)
- Giora Weisz
- Shaare Zedek Medical Center, Jerusalem, Israel; New York Presbyterian Hospital, Columbia University Medical Center, New York, NY, USA; Cardiovascular Research Foundation, New York, NY, USA.
| | - Philippe Généreux
- Cardiovascular Research Foundation, New York, NY, USA; Hôpital du Sacré-Coeur de Montreal, Université de Montreal, Montreal, QC, Canada
| | | | | | | | - Karen P Alexander
- Duke Clinical Research Institute and Duke University, Durham, NC, USA
| | | | | | - Stefan James
- Department of Medical Sciences, Cardiology, Uppsala University, Uppsala, Sweden
| | - E Magnus Ohman
- Duke Clinical Research Institute and Duke University, Durham, NC, USA
| | | | | | - Gregg W Stone
- New York Presbyterian Hospital, Columbia University Medical Center, New York, NY, USA; Cardiovascular Research Foundation, New York, NY, USA
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Sedlis SP, Hartigan PM, Teo KK, Maron DJ, Spertus JA, Mancini GBJ, Kostuk W, Chaitman BR, Berman D, Lorin JD, Dada M, Weintraub WS, Boden WE. Effect of PCI on Long-Term Survival in Patients with Stable Ischemic Heart Disease. N Engl J Med 2015; 373:1937-46. [PMID: 26559572 PMCID: PMC5656049 DOI: 10.1056/nejmoa1505532] [Citation(s) in RCA: 184] [Impact Index Per Article: 20.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
BACKGROUND Percutaneous coronary intervention (PCI) relieves angina in patients with stable ischemic heart disease, but clinical trials have not shown that it improves survival. Between June 1999 and January 2004, we randomly assigned 2287 patients with stable ischemic heart disease to an initial management strategy of optimal medical therapy alone (medical-therapy group) or optimal medical therapy plus PCI (PCI group) and did not find a significant difference in the rate of survival during a median follow-up of 4.6 years. We now report the rate of survival among the patients who were followed for up to 15 years. METHODS We obtained permission from the patients at the Department of Veterans Affairs (VA) sites and some non-VA sites in the United States to use their Social Security numbers to track their survival after the original trial period ended. We searched the VA national Corporate Data Warehouse and the National Death Index for survival information and the dates of death from any cause. We calculated survival according to the Kaplan-Meier method and used a Cox proportional-hazards model to adjust for significant between-group differences in baseline characteristics. RESULTS Extended survival information was available for 1211 patients (53% of the original population). The median duration of follow-up for all patients was 6.2 years (range, 0 to 15); the median duration of follow-up for patients at the sites that permitted survival tracking was 11.9 years (range, 0 to 15). A total of 561 deaths (180 during the follow-up period in the original trial and 381 during the extended follow-up period) occurred: 284 deaths (25%) in the PCI group and 277 (24%) in the medical-therapy group (adjusted hazard ratio, 1.03; 95% confidence interval, 0.83 to 1.21; P=0.76). CONCLUSIONS During an extended-follow-up of up to 15 years, we did not find a difference in survival between an initial strategy of PCI plus medical therapy and medical therapy alone in patients with stable ischemic heart disease. (Funded by the VA Cooperative Studies Program and others; COURAGE ClinicalTrials.gov number, NCT00007657.).
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Affiliation(s)
- Steven P Sedlis
- From the New York Veterans Affairs (VA) Healthcare Network, New York (S.P.S., J.D.L.), and Upstate New York VA Healthcare Network and Albany Medical College, Albany (W.E.B.) - all in New York; VA Connecticut Healthcare System, West Haven (P.M.H.) and Hartford Hospital, Hartford (M.D.) - both in Connecticut; McMaster University Medical Center, Hamilton, ON (K.K.T.), Vancouver Hospital and Health Sciences Center, Vancouver, BC (G.B.J.M.), and London Health Sciences Centre, London, ON (W.K.) - all in Canada; Stanford University Medical Center, Stanford, CA (D.J.M.); Mid-America Heart Institute, University of Missouri, Kansas City, Kansas City (J.A.S.); Saint Louis University School of Medicine, St. Louis (B.R.C.); Cedars-Sinai Medical Center, Los Angeles (D.B.); and Christiana Care Health System, Newark, DE (W.S.W.)
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Abstract
The keynote COURAGE and BARI-2D trials changed the way the interventional community selects patients for revascularization. What we now consider appropriate, especially for percutaneous coronary intervention, has narrowed significantly in scope compared to previous practice a decade ago. Medical therapy has been shown to be both safe and effective as a primary treatment modality for patients with stable ischemic heart disease on the whole. However, it appears that patients with a heavy ischemic burden may benefit from revascularization, although investigation of this is ongoing. Evidence preliminarily supports this practice with coronary artery bypass grafting, and possibly in specific populations undergoing multivessel intervention with functional assessment of lesion severity during PCI.
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Reynolds HR, Picard MH, Hochman JS. Does ischemia burden in stable coronary artery disease effectively identify revascularization candidates? Ischemia burden in stable coronary artery disease does not effectively identify revascularization candidates. Circ Cardiovasc Imaging 2015; 8:discussion p 9. [PMID: 25977302 DOI: 10.1161/circimaging.113.000362] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Harmony R Reynolds
- From the Cardiovascular Clinical Research Center, Leon Charney Division of Cardiology and Department of Medicine, NYU Langone Medical Center, New York, NY (H.R.R., J.S.H.); and Division of Cardiology and Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston (M.H.P.).
| | - Michael H Picard
- From the Cardiovascular Clinical Research Center, Leon Charney Division of Cardiology and Department of Medicine, NYU Langone Medical Center, New York, NY (H.R.R., J.S.H.); and Division of Cardiology and Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston (M.H.P.)
| | - Judith S Hochman
- From the Cardiovascular Clinical Research Center, Leon Charney Division of Cardiology and Department of Medicine, NYU Langone Medical Center, New York, NY (H.R.R., J.S.H.); and Division of Cardiology and Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston (M.H.P.)
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17
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Sidhu MS, Boden WE. The continued importance of optimal medical therapy with or without revascularization in diabetic patients with coronary artery disease. Trends Cardiovasc Med 2015; 25:632-4. [PMID: 25957809 DOI: 10.1016/j.tcm.2015.04.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2015] [Accepted: 04/03/2015] [Indexed: 11/25/2022]
Affiliation(s)
- Mandeep S Sidhu
- Division of Cardiology, Department of Medicine, Albany Medical College, Albany, NY; Division of Cardiology, Department of Medicine, Albany Stratton VA Medical Center, Albany, NY.
| | - William E Boden
- Division of Cardiology, Department of Medicine, Albany Medical College, Albany, NY; Division of Cardiology, Department of Medicine, Albany Stratton VA Medical Center, Albany, NY
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18
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Scott P, Farouque O, Clark D. Percutaneous coronary intervention in women: should management be different? Interv Cardiol 2014. [DOI: 10.2217/ica.14.51] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
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19
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Evaluation of the stable coronary artery disease patient: Anatomy trumps physiology. Trends Cardiovasc Med 2014; 24:332-40. [DOI: 10.1016/j.tcm.2014.08.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2014] [Revised: 07/17/2014] [Accepted: 08/09/2014] [Indexed: 11/21/2022]
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20
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Sex differences in independent factors associated with coronary artery disease. Wien Klin Wochenschr 2014; 126:718-26. [PMID: 25216757 DOI: 10.1007/s00508-014-0602-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2014] [Accepted: 08/24/2014] [Indexed: 01/14/2023]
Abstract
BACKGROUND Women undergoing coronary angiography (CA) due to chest pain are more likely to present with less extensive coronary artery disease (CAD) than men, which might be attributed to different effects of cardiovascular risk factors on coronary atherogenesis between sexes. The aim of the present study was to evaluate sex differences in independent factors associated with obstructive and non-obstructive CAD in a large consecutive cohort of patients undergoing elective CA. METHODS Data from 7819 patients (2653 women and 5184 men), including cardiovascular risk factors, clinical presentation, CAD severity and treatment decisions were analysed. RESULTS Women were older than men (65 ± 11 vs. 63 ± 11 years, p < 0.001); low-density lipoprotein cholesterol (LDL; 125 ± 38 vs. 122 ± 37 mg/dL, p < 0.001) and high-density lipoprotein cholesterol (HDL) cholesterol levels (62 ± 18 vs. 51 ± 15 mg/dL, p < 0.001) were higher in women; and smokers were more frequently men (14.4 vs. 20.1%, p < 0.001). Men more frequently had an obstructive CAD (41.1 vs. 65.6%, p < 0.001). Multivariable analyses revealed age, HDL cholesterol, hypercholesterolaemia, diabetes mellitus, arterial hypertension and a positive family history being associated with obstructive CAD in both sexes, whereas smoking was independently associated with obstructive CAD only in women. The association of hypercholesterolaemia with obstructive CAD was stronger in men. For non-obstructive CAD, no sex-specific associated factors could be identified. CONCLUSION The impact of smoking and hypercholesterolaemia on coronary atherosclerosis is different between women and men. This might be taken into account when planning individual interventions to reduce cardiovascular risk.
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Mancini GJ, Gosselin G, Chow B, Kostuk W, Stone J, Yvorchuk KJ, Abramson BL, Cartier R, Huckell V, Tardif JC, Connelly K, Ducas J, Farkouh ME, Gupta M, Juneau M, O’Neill B, Raggi P, Teo K, Verma S, Zimmermann R. Canadian Cardiovascular Society Guidelines for the Diagnosis and Management of Stable Ischemic Heart Disease. Can J Cardiol 2014; 30:837-49. [DOI: 10.1016/j.cjca.2014.05.013] [Citation(s) in RCA: 87] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2014] [Revised: 05/22/2014] [Accepted: 05/23/2014] [Indexed: 02/05/2023] Open
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22
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Mancini GBJ, Hartigan PM, Shaw LJ, Berman DS, Hayes SW, Bates ER, Maron DJ, Teo K, Sedlis SP, Chaitman BR, Weintraub WS, Spertus JA, Kostuk WJ, Dada M, Booth DC, Boden WE. Predicting outcome in the COURAGE trial (Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation): coronary anatomy versus ischemia. JACC Cardiovasc Interv 2014; 7:195-201. [PMID: 24440015 DOI: 10.1016/j.jcin.2013.10.017] [Citation(s) in RCA: 159] [Impact Index Per Article: 15.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2013] [Revised: 10/12/2013] [Accepted: 10/24/2013] [Indexed: 02/08/2023]
Abstract
OBJECTIVES The aim of this study was to determine the relative utility of anatomic and ischemic burden of coronary artery disease for predicting outcomes. BACKGROUND Both anatomic burden and ischemic burden of coronary artery disease determine patient prognosis and influence myocardial revascularization decisions. When both measures are available, their relative utility for prognostication and management choice is controversial. METHODS A total of 621 patients enrolled in the COURAGE (Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation) trial with baseline quantitative nuclear single-photon emission computed tomography (SPECT) and quantitative coronary angiography were studied. Several multiple regression models were constructed to determine independent predictors of the endpoint of death, myocardial infarction (MI) (excluding periprocedural MI) and non-ST-segment elevation acute coronary syndromes (NSTE-ACS). Ischemic burden during stress SPECT, anatomic burden derived from angiography, left ventricular ejection fraction, and assignment to either optimal medical therapy (OMT) + percutaneous coronary intervention (PCI) or OMT alone were analyzed. RESULTS In nonadjusted and adjusted regression models, anatomic burden and left ventricular ejection fraction were consistent predictors of death, MI, and NSTE-ACS, whereas ischemic burden and treatment assignment were not. There was a marginal (p = 0.03) effect of the interaction term of anatomic and ischemic burden for the prediction of clinical outcome, but separately or in combination, neither anatomy nor ischemia interacted with therapeutic strategy to predict outcome. CONCLUSIONS In a cohort of patients treated with OMT, anatomic burden was a consistent predictor of death, MI, and NSTE-ACS, whereas ischemic burden was not. Importantly, neither determination, even in combination, identified a patient profile benefiting preferentially from an invasive therapeutic strategy. (Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation [COURAGE]; NCT00007657).
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Affiliation(s)
- G B John Mancini
- University of British Columbia, Vancouver, British Columbia, Canada.
| | - Pamela M Hartigan
- Veterans Affairs Cooperative Studies Program Coordinating Center, Connecticut VA Healthcare System, West Haven, Connecticut
| | - Leslee J Shaw
- Emory University School of Medicine, Atlanta, Georgia
| | - Daniel S Berman
- Cedars-Sinai Heart Institute, University of California, Los Angeles, California
| | - Sean W Hayes
- Cedars-Sinai Heart Institute, University of California, Los Angeles, California
| | - Eric R Bates
- University of Michigan Medical Center, Ann Arbor, Michigan
| | - David J Maron
- Vanderbilt University Medical Center, Nashville, Tennessee
| | - Koon Teo
- McMaster University Medical Center, Hamilton, Ontario, Canada
| | - Steven P Sedlis
- VA New York Harbor Healthcare System, New York Campus, New York University School of Medicine, New York, New York
| | | | | | - John A Spertus
- Mid America Heart Institute, University of Missouri, Kansas City, Missouri
| | - William J Kostuk
- London Health Sciences Centre, University of Western Ontario, London, Ontario, Canada
| | | | | | - William E Boden
- New York Health Care System, Buffalo General Hospital and the State University of New York at Buffalo, Buffalo, New York
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Weisz G, Farzaneh-Far R, Ben-Yehuda O, DeBruyne B, Montalescot G, Lerman A, Mahmud E, Alexander KP, Ohman EM, White HD, Olmsted A, Walker GA, Stone GW. Use of ranolazine in patients with incomplete revascularization after percutaneous coronary intervention: design and rationale of the Ranolazine for Incomplete Vessel Revascularization Post-Percutaneous Coronary Intervention (RIVER-PCI) trial. Am Heart J 2013; 166:953-959.e3. [PMID: 24268208 DOI: 10.1016/j.ahj.2013.08.004] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2013] [Accepted: 08/14/2013] [Indexed: 12/19/2022]
Abstract
BACKGROUND Incomplete revascularization (ICR) after percutaneous coronary intervention (PCI) is common and is associated with increased rates of rehospitalization, revascularization, and mortality. Adjunctive pharmacotherapy with ranolazine, an inhibitor of the late sodium current with anti-ischemic properties, may be effective in reducing recurrent events after PCI in patients with ICR. TRIAL DESIGN RIVER-PCI is a phase 3, randomized, double-blind, placebo-controlled, international event-driven clinical trial evaluating the efficacy of ranolazine in patients with a history of chronic angina and ICR after PCI. Approximately 2,600 participants with ICR post-PCI will be randomized in a 1:1 ratio to ranolazine or matched placebo within 14 days of an index PCI. The primary end point of the trial is time to the first occurrence of ischemia-driven revascularization or ischemia-driven hospitalization without revascularization. Participants will be followed up for a minimum of 1 year and until at least 720 confirmed primary end point events have occurred. Secondary end points include sudden cardiac death, cardiovascular death, myocardial infarction, and measures of quality of life and cost-effectiveness. The evaluation of long-term safety will include all-cause mortality, stroke, transient ischemic attack, and hospitalization for heart failure. Enrollment commenced in November 2011 and was completed in summer 2013. CONCLUSIONS RIVER-PCI is a novel, large-scale, international, randomized, double-blind, placebo-controlled clinical trial evaluating the role of ranolazine in the long-term medical management of patients with ICR post-PCI.
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Mancini GBJ, Hartigan PM, Bates ER, Chaitman BR, Sedlis SP, Maron DJ, Kostuk WJ, Spertus JA, Teo KK, Dada M, Knudtson M, Berman DS, Booth DC, Boden WE, Weintraub WS. Prognostic importance of coronary anatomy and left ventricular ejection fraction despite optimal therapy: assessment of residual risk in the Clinical Outcomes Utilizing Revascularization and Aggressive DruG Evaluation Trial. Am Heart J 2013; 166:481-7. [PMID: 24016497 DOI: 10.1016/j.ahj.2013.07.007] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2013] [Accepted: 07/01/2013] [Indexed: 11/29/2022]
Abstract
BACKGROUND It is unknown if baseline angiographic findings can be used to estimate residual risk of patients with chronic stable angina treated with both optimal medical therapy (OMT) and protocol-assigned or symptom-driven percutaneous coronary intervention (PCI). METHODS Death, myocardial infarction (MI), and hospitalization for non-ST-segment elevation acute coronary syndrome were adjudicated in 2,275 COURAGE patients. The number of vessels diseased (VD) was defined as the number of major coronary arteries with ≥50% diameter stenosis. Proximal left anterior descending, either isolated or in combination with other disease, was also evaluated. Depressed left ventricular ejection fraction (LVEF) was defined as ≤50%. Cox regression analyses included these anatomical factors as well as interaction terms for initial treatment assignment (OMT or OMT + PCI). RESULTS Percutaneous coronary intervention and proximal left anterior descending did not influence any outcome. Death was predicted by low LVEF (hazard ratio [HR] 1.86, CI 1.34-2.59, P < .001) and VD (HR 1.45, CI 1.20-1.75, P < .001). Myocardial infarction and non-ST-segment elevation acute coronary syndrome were predicted only by VD (HR 1.53, CI 1.30-1.81 and HR 1.24, CI 1.06-1.44, P = .007, respectively). CONCLUSIONS In spite of OMT and irrespective of protocol-assigned or clinically driven PCI, LVEF and angiographic burden of disease at baseline retain prognostic power and reflect residual risk for secondary ischemic events.
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Affiliation(s)
- G B John Mancini
- University of British Columbia, Vancouver, British Columbia, Canada.
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Maron DJ, Ting HH. In mildly symptomatic patients, should an invasive strategy with catheterization and revascularization be routinely undertaken?: in mildly symptomatic patients, an invasive strategy with catheterization and revascularization should not be routinely undertaken. Circ Cardiovasc Interv 2013; 6:114-21; discussion 121. [PMID: 23424271 DOI: 10.1161/circinterventions.112.973438] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Affiliation(s)
- David J Maron
- Department of Medicine, Vanderbilt University School of Medicine, Nashville, TN 37232-8800, USA.
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Spertus JA, Maron DJ, Cohen DJ, Kolm P, Hartigan P, Weintraub WS, Berman DS, Teo KK, Shaw LJ, Sedlis SP, Knudtson M, Aslan M, Dada M, Boden WE, Mancini GBJ. Frequency, predictors, and consequences of crossing over to revascularization within 12 months of randomization to optimal medical therapy in the Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation (COURAGE) trial. Circ Cardiovasc Qual Outcomes 2013; 6:409-18. [PMID: 23838107 DOI: 10.1161/circoutcomes.113.000139] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND In the Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation (COURAGE) trial, some patients with stable ischemic heart disease randomized to optimal medical therapy (OMT) crossed over to early revascularization. The predictors and outcomes of patients who crossed over from OMT to revascularization are unknown. METHODS AND RESULTS We compared characteristics of OMT patients who did and did not undergo revascularization within 12 months and created a Cox regression model to identify predictors of early revascularization. Patients' health status was measured with the Seattle Angina Questionnaire. To quantify the potential consequences of initiating OMT without percutaneous coronary intervention, we compared the outcomes of crossover patients with a matched cohort randomized to immediate percutaneous coronary intervention. Among 1148 patients randomized to OMT, 185 (16.1%) underwent early revascularization. Patient characteristics independently associated with early revascularization were worse baseline Seattle Angina Questionnaire scores and healthcare system. Among 156 OMT patients undergoing early revascularization matched to 156 patients randomized to percutaneous coronary intervention, rates of mortality (hazard ratio=0.51 [0.13-2.1]) and nonfatal myocardial infarction (hazard ratio=1.9 [0.75-4.6]) were similar, as were 1-year Seattle Angina Questionnaire scores. OMT patients, however, experienced worse health status over the initial year of treatment and more unstable angina admissions (hazard ratio=2.8 [1.1-7.5]). CONCLUSION Among COURAGE patients assigned to OMT alone, patients' angina, dissatisfaction with their current treatment, and, to a lesser extent, their health system were associated with early revascularization. Because early crossover was not associated with an increase in irreversible ischemic events or impaired 12-month health status, these findings support an initial trial of OMT in stable ischemic heart disease with close follow-up of the most symptomatic patients. CLINICAL TRIAL REGISTRATION URL: http://www.clinicaltrials.gov. Unique identifier: NCT00007657.
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Affiliation(s)
- John A Spertus
- Department of Cardiovascular Research, Saint Luke's Mid America Heart Institute, University of Missouri-Kansas City, Kansas City, MO, USA.
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Mecklai A, Bangalore S, Hochman J. How and when to decide on revascularization in stable ischemic heart disease. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2013; 15:79-92. [PMID: 23143818 DOI: 10.1007/s11936-012-0214-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
OPINION STATEMENT Coronary artery disease is the leading cause of death and disability worldwide. While an invasive strategy of early revascularization reduces cardiovascular morbidity and mortality in patients with acute coronary syndromes, there is no convincing evidence that this strategy leads to an incremental survival advantage for patients with stable ischemic heart disease (SIHD) beyond that achieved by optimal medical therapy. Two landmark trials, COURAGE and BARI 2D, suggest that a strategy of aggressive medical therapy is a reasonable initial approach to such patients. However, there remain certain groups of patients, those with at least moderate ischemia on baseline stress testing, where there is still clinical equipoise. Major society guidelines favor revascularization based on observational data and trials of CABG conducted decades ago, yet data from modern randomized trials are lacking. Ongoing trials such as ISCHEMIA should provide clinicians with evidence to guide selection of the appropriate initial management strategy for patients with SIHD.
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Affiliation(s)
- Alicia Mecklai
- Leon Charney Division of Cardiology, New York University School of Medicine, 530 First Avenue, Skirball 9R, New York, NY, 10016, USA
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William Edward Boden, MD: a conversation with the editor. Am J Cardiol 2012; 110:145-59. [PMID: 22704294 DOI: 10.1016/j.amjcard.2012.02.035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2012] [Accepted: 03/22/2012] [Indexed: 11/22/2022]
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Mancini GJ, Hartigan PM, Bates ER, Sedlis SP, Maron DJ, Spertus JA, Berman DS, Kostuk WJ, Shaw LJ, Weintraub WS, Teo KK, Dada M, Chaitman BR, O'Rourke RA, Boden WE. Angiographic Disease Progression and Residual Risk of Cardiovascular Events While on Optimal Medical Therapy. Circ Cardiovasc Interv 2011; 4:545-52. [DOI: 10.1161/circinterventions.110.960062] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
Background—
The extent to which recurrent events in patients with stable coronary artery disease is attributable to progression of an index lesion originally ≥50% diameter stenosis (DS) but not revascularized or originally <50% DS is unknown during optimal medical therapy (OMT).
Methods and Results—
In the COURAGE (Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation) trial, 205 patients assigned to OMT plus percutaneous coronary intervention (PCI) and 284 patients assigned to OMT only had symptom-driven angiograms suitable for analysis. Percentages of patients in the OMT+PCI and OMT-only cohorts with index lesions originally <50% DS were 30% and 32%, respectively; 20% and 68% had index lesions originally ≥50% DS. In both groups, index lesions originally <50% or ≥50% DS represented <4% and <25% of all such lesions, respectively. The only angiographic predictor of myocardial infarction or acute coronary syndrome was the number of lesions originally ≥50% DS that had not been revascularized (odds ratio, 1.15; confidence limits, 1.01–1.31;
P
<0.04).
Conclusions—
Lesions originally <50% DS were index lesions in one third of patients referred for symptom-driven repeat angiography, but represented <4% of all such lesions. Nonrevascularized lesions originally ≥50% DS were more often index lesions in OMT-only patients, but still represented a minority (<25%) of all such lesions. These findings underscore the need for improved therapies to arrest plaque progression and reliable strategies for selecting stenoses warranting PCI.
Clinical Trial Registration—
URL:
http://www.clinicaltrials.gov
. Unique identifier: NCT00007657.
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Affiliation(s)
- G.B. John Mancini
- From the University of British Columbia, Vancouver, British Columbia, Canada (G.B.J.M.); Veterans Affairs Cooperative Studies Program Coordinating Center, Connecticut VA Healthcare System, West Haven, CT (P.M.H.); University of Michigan Medical Center, Ann Arbor, MI (E.R.B.); VA New York Harbor Health Care System, New York Campus, New York, University School of Medicine, New York, NY (S.P.S.); Vanderbilt University Medical Center, Nashville, TN (D.J.M.); Mid America Heart Institute, University of
| | - Pamela M. Hartigan
- From the University of British Columbia, Vancouver, British Columbia, Canada (G.B.J.M.); Veterans Affairs Cooperative Studies Program Coordinating Center, Connecticut VA Healthcare System, West Haven, CT (P.M.H.); University of Michigan Medical Center, Ann Arbor, MI (E.R.B.); VA New York Harbor Health Care System, New York Campus, New York, University School of Medicine, New York, NY (S.P.S.); Vanderbilt University Medical Center, Nashville, TN (D.J.M.); Mid America Heart Institute, University of
| | - Eric R. Bates
- From the University of British Columbia, Vancouver, British Columbia, Canada (G.B.J.M.); Veterans Affairs Cooperative Studies Program Coordinating Center, Connecticut VA Healthcare System, West Haven, CT (P.M.H.); University of Michigan Medical Center, Ann Arbor, MI (E.R.B.); VA New York Harbor Health Care System, New York Campus, New York, University School of Medicine, New York, NY (S.P.S.); Vanderbilt University Medical Center, Nashville, TN (D.J.M.); Mid America Heart Institute, University of
| | - Steven P. Sedlis
- From the University of British Columbia, Vancouver, British Columbia, Canada (G.B.J.M.); Veterans Affairs Cooperative Studies Program Coordinating Center, Connecticut VA Healthcare System, West Haven, CT (P.M.H.); University of Michigan Medical Center, Ann Arbor, MI (E.R.B.); VA New York Harbor Health Care System, New York Campus, New York, University School of Medicine, New York, NY (S.P.S.); Vanderbilt University Medical Center, Nashville, TN (D.J.M.); Mid America Heart Institute, University of
| | - David J. Maron
- From the University of British Columbia, Vancouver, British Columbia, Canada (G.B.J.M.); Veterans Affairs Cooperative Studies Program Coordinating Center, Connecticut VA Healthcare System, West Haven, CT (P.M.H.); University of Michigan Medical Center, Ann Arbor, MI (E.R.B.); VA New York Harbor Health Care System, New York Campus, New York, University School of Medicine, New York, NY (S.P.S.); Vanderbilt University Medical Center, Nashville, TN (D.J.M.); Mid America Heart Institute, University of
| | - John A. Spertus
- From the University of British Columbia, Vancouver, British Columbia, Canada (G.B.J.M.); Veterans Affairs Cooperative Studies Program Coordinating Center, Connecticut VA Healthcare System, West Haven, CT (P.M.H.); University of Michigan Medical Center, Ann Arbor, MI (E.R.B.); VA New York Harbor Health Care System, New York Campus, New York, University School of Medicine, New York, NY (S.P.S.); Vanderbilt University Medical Center, Nashville, TN (D.J.M.); Mid America Heart Institute, University of
| | - Daniel S. Berman
- From the University of British Columbia, Vancouver, British Columbia, Canada (G.B.J.M.); Veterans Affairs Cooperative Studies Program Coordinating Center, Connecticut VA Healthcare System, West Haven, CT (P.M.H.); University of Michigan Medical Center, Ann Arbor, MI (E.R.B.); VA New York Harbor Health Care System, New York Campus, New York, University School of Medicine, New York, NY (S.P.S.); Vanderbilt University Medical Center, Nashville, TN (D.J.M.); Mid America Heart Institute, University of
| | - William J. Kostuk
- From the University of British Columbia, Vancouver, British Columbia, Canada (G.B.J.M.); Veterans Affairs Cooperative Studies Program Coordinating Center, Connecticut VA Healthcare System, West Haven, CT (P.M.H.); University of Michigan Medical Center, Ann Arbor, MI (E.R.B.); VA New York Harbor Health Care System, New York Campus, New York, University School of Medicine, New York, NY (S.P.S.); Vanderbilt University Medical Center, Nashville, TN (D.J.M.); Mid America Heart Institute, University of
| | - Leslee J. Shaw
- From the University of British Columbia, Vancouver, British Columbia, Canada (G.B.J.M.); Veterans Affairs Cooperative Studies Program Coordinating Center, Connecticut VA Healthcare System, West Haven, CT (P.M.H.); University of Michigan Medical Center, Ann Arbor, MI (E.R.B.); VA New York Harbor Health Care System, New York Campus, New York, University School of Medicine, New York, NY (S.P.S.); Vanderbilt University Medical Center, Nashville, TN (D.J.M.); Mid America Heart Institute, University of
| | - William S. Weintraub
- From the University of British Columbia, Vancouver, British Columbia, Canada (G.B.J.M.); Veterans Affairs Cooperative Studies Program Coordinating Center, Connecticut VA Healthcare System, West Haven, CT (P.M.H.); University of Michigan Medical Center, Ann Arbor, MI (E.R.B.); VA New York Harbor Health Care System, New York Campus, New York, University School of Medicine, New York, NY (S.P.S.); Vanderbilt University Medical Center, Nashville, TN (D.J.M.); Mid America Heart Institute, University of
| | - Koon K. Teo
- From the University of British Columbia, Vancouver, British Columbia, Canada (G.B.J.M.); Veterans Affairs Cooperative Studies Program Coordinating Center, Connecticut VA Healthcare System, West Haven, CT (P.M.H.); University of Michigan Medical Center, Ann Arbor, MI (E.R.B.); VA New York Harbor Health Care System, New York Campus, New York, University School of Medicine, New York, NY (S.P.S.); Vanderbilt University Medical Center, Nashville, TN (D.J.M.); Mid America Heart Institute, University of
| | - Marcin Dada
- From the University of British Columbia, Vancouver, British Columbia, Canada (G.B.J.M.); Veterans Affairs Cooperative Studies Program Coordinating Center, Connecticut VA Healthcare System, West Haven, CT (P.M.H.); University of Michigan Medical Center, Ann Arbor, MI (E.R.B.); VA New York Harbor Health Care System, New York Campus, New York, University School of Medicine, New York, NY (S.P.S.); Vanderbilt University Medical Center, Nashville, TN (D.J.M.); Mid America Heart Institute, University of
| | - Bernard R. Chaitman
- From the University of British Columbia, Vancouver, British Columbia, Canada (G.B.J.M.); Veterans Affairs Cooperative Studies Program Coordinating Center, Connecticut VA Healthcare System, West Haven, CT (P.M.H.); University of Michigan Medical Center, Ann Arbor, MI (E.R.B.); VA New York Harbor Health Care System, New York Campus, New York, University School of Medicine, New York, NY (S.P.S.); Vanderbilt University Medical Center, Nashville, TN (D.J.M.); Mid America Heart Institute, University of
| | - Robert A. O'Rourke
- From the University of British Columbia, Vancouver, British Columbia, Canada (G.B.J.M.); Veterans Affairs Cooperative Studies Program Coordinating Center, Connecticut VA Healthcare System, West Haven, CT (P.M.H.); University of Michigan Medical Center, Ann Arbor, MI (E.R.B.); VA New York Harbor Health Care System, New York Campus, New York, University School of Medicine, New York, NY (S.P.S.); Vanderbilt University Medical Center, Nashville, TN (D.J.M.); Mid America Heart Institute, University of
| | - William E. Boden
- From the University of British Columbia, Vancouver, British Columbia, Canada (G.B.J.M.); Veterans Affairs Cooperative Studies Program Coordinating Center, Connecticut VA Healthcare System, West Haven, CT (P.M.H.); University of Michigan Medical Center, Ann Arbor, MI (E.R.B.); VA New York Harbor Health Care System, New York Campus, New York, University School of Medicine, New York, NY (S.P.S.); Vanderbilt University Medical Center, Nashville, TN (D.J.M.); Mid America Heart Institute, University of
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Affiliation(s)
- Harlan M. Krumholz
- From the Section of Cardiovascular Medicine and the Robert Wood Johnson Clinical Scholars Program, Department of Internal Medicine, Yale University School of Medicine; the Section of Health Policy and Administration, Yale School of Public Health; and the Center for Outcomes Research and Evaluation, Yale–New Haven Hospital, New Haven, CT
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Percutaneous revascularization for stable coronary artery disease: temporal trends and impact of drug-eluting stents. JACC Cardiovasc Interv 2010; 3:566; author reply 566-7. [PMID: 20488418 DOI: 10.1016/j.jcin.2010.03.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2010] [Accepted: 03/18/2010] [Indexed: 11/21/2022]
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Chaitman BR, Hartigan PM, Booth DC, Teo KK, Mancini GBJ, Kostuk WJ, Spertus JA, Maron DJ, Dada M, O'Rourke RA, Weintraub WS, Berman DS, Shaw LJ, Boden WE. Do major cardiovascular outcomes in patients with stable ischemic heart disease in the clinical outcomes utilizing revascularization and aggressive drug evaluation trial differ by healthcare system? Circ Cardiovasc Qual Outcomes 2010; 3:476-83. [PMID: 20664026 DOI: 10.1161/circoutcomes.109.901579] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND The Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation (COURAGE) trial enrolled patients from 3 distinct healthcare systems (HCSs) in North America. The primary aim of this study was to determine whether there is a treatment difference in cardiovascular outcomes by HCS. METHODS AND RESULTS The study population included 968 patients from the US Department of Veterans Affairs (VA), 386 from the US non-VA, and 931 from Canada with different comorbidities and prognoses. The primary outcome was all-cause mortality or nonfatal myocardial infarction (MI) during the median 4.6-year follow-up. Baseline demographics were similar between percutaneous coronary intervention and optimal medical therapy treatment groups within each HCS. After follow-up, the primary end point of total mortality and nonfatal MI was not statistically significant between percutaneous coronary intervention and optimal medical therapy, regardless of HCS: VA, 22.3% versus 21.9% (hazard ratio, 1.05; 95% CI, 0.80-1.38; P=0.95); US non-VA, 15.8% versus 21.8% (hazard ratio, 0.70; 95% CI, 0.43-1.12; P=0.24); Canadian HCS, 17.3% versus 13.5% (hazard ratio, 1.30; 95% CI, 0.93-1.83; P=0.17). The interaction between HCSs and treatment was not statistically significant. Long-term mortality was significantly higher in the VA system as a result of significantly greater comorbidity and worse left ventricular function. CONCLUSIONS In the COURAGE trial, addition of percutaneous coronary intervention to optimal medical therapy did not improve 5-year survival or reduce MI or other major adverse cardiovascular events regardless of whether patients were Canadian or American or US veterans or non-veterans. Outcome differences were largely explained by differences in baseline characteristics known to affect long-term prognosis.
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Affiliation(s)
- Bernard R Chaitman
- Department of Internal Medicine, Saint Louis University School of Medicine, 1034 S Brentwood Blvd., St Louis, MO 63117, USA.
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Affiliation(s)
- Harlan M. Krumholz
- From the Section of Cardiovascular Medicine and the Robert Wood Johnson Clinical Scholars Program, Department of Medicine; Section of Health Policy and Administration, School of Public Health, Yale University School of Medicine; and the Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, Conn
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