1
|
Bi L, Geng Y, Wang Y, Li S, Sun K, Guo Y, Zhang O, Zhang P. An updated meta-analysis of optimal medical therapy with or without invasive therapy in patients with stable coronary artery disease. BMC Cardiovasc Disord 2024; 24:335. [PMID: 38961354 PMCID: PMC11223390 DOI: 10.1186/s12872-024-03997-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2024] [Accepted: 06/20/2024] [Indexed: 07/05/2024] Open
Abstract
BACKGROUND The efficacy of optimal medical therapy (OMT) with or without revascularization therapy in patients with stable coronary artery disease (SCAD) remains controversial. We performed a meta-analysis of randomized controlled trials (RCTs) that compared OMT with or without revascularization therapy for SCAD patients. METHODS Studies were searched in PubMed, EMBASE, and the Cochrane Central Register of Clinical Trials from January 1, 2005, to December 30, 2023. The main efficacy outcome was a composite of all-cause death, myocadiac infarction, revascularization, and cerebrovascular accident. Results were pooled using random effects model and fixed effects model and are presented as odd ratios (ORs) with 95% confidence intervals (CI). RESULTS Ten studies involving 12,790 participants were included. The arm of OMT with revascularization compared with OMT alone was associated with decreased risks for MACCE (OR 0.55 [95% CI 0.38-0.80], I²=93%, P = 0.002), CV death (OR 0.84 [95% CI 0.73-0.97], I²=36%, P = 0.02), revascularization (OR 0.32 [95% CI 0.20-0.50], I²=92%, P < 0.001), and MI (OR 0.85 [95% CI 0.76-0.96], I²=45%, P = 0.007). While there was no significant difference between OMT with revascularization and OMT alone in the odds of all-cause death (OR 0.94 [95% CI 0.84-1.05], I²=0%, P = 0.30). CONCLUSIONS The current updated meta-analysis of 10 RCTs shows that in patients with SCAD, OMT with revascularization would reduce the risk for MACCE, cardiovascular death, and MI. However, the invasive strategy does not decrease the risks for all-cause mortality when comparing with OMT alone.
Collapse
Affiliation(s)
- Lei Bi
- Department of Cardiology, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, NO. 168 Litang Road, Changping District, Beijing, 102218, P. R. China
| | - Yu Geng
- Department of Cardiology, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, NO. 168 Litang Road, Changping District, Beijing, 102218, P. R. China
| | - Yintang Wang
- Department of Cardiology, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, NO. 168 Litang Road, Changping District, Beijing, 102218, P. R. China
| | - Siyuan Li
- Department of Cardiology, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, NO. 168 Litang Road, Changping District, Beijing, 102218, P. R. China
| | - Kuogen Sun
- Beijing Changping District Tiantongyuan North Community Healthcare Center, Beijing, China
| | - Yiqi Guo
- Department of Emergency, Tsinghua University Hospital, Beijing, China
| | - Ou Zhang
- Department of Cardiology, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, NO. 168 Litang Road, Changping District, Beijing, 102218, P. R. China.
| | - Ping Zhang
- Department of Cardiology, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, NO. 168 Litang Road, Changping District, Beijing, 102218, P. R. China.
| |
Collapse
|
2
|
Vergallo R, Galiuto L. Weekly journal scan: angina severity reduced by percutaneous coronary intervention in the ORBITA-2 trial. Eur Heart J 2024; 45:1874-1876. [PMID: 38596889 DOI: 10.1093/eurheartj/ehae215] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/11/2024] Open
Affiliation(s)
- Rocco Vergallo
- Interventional Cardiology Unit, Cardiothoracic and Vascular Department (DICATOV), IRCCS Ospedale Policlinico San Martino, Viale Benedetto XV, 6, 16132 Genova, Italy
- Department of Internal Medicine and Medical Specialties (DIMI), Università di Genova, Largo R. Benzi, 10, 16132 Genova, Italy
| | - Leonarda Galiuto
- Department of Clinical and Molecular Medicine, Sapienza University of Rome, Azienda Ospedaliero-Universitaria S. Andrea, Rome, Italy
| |
Collapse
|
3
|
Llerena-Velastegui J, Zumbana-Podaneva K, Velastegui-Zurita S, Mejia-Mora M, Perez-Tomassetti J, Cabrera-Cruz A, Haro-Arteaga P, de Jesus ACFS, Coelho PM, Sanahuja-Montiel C. Comparative Efficacy of Percutaneous Coronary Intervention Versus Coronary Artery Bypass Grafting in the Treatment of Ischemic Heart Disease: A Systematic Review and Meta-Analysis of Recent Randomized Controlled Trials. Cardiol Res 2024; 15:153-168. [PMID: 38994227 PMCID: PMC11236347 DOI: 10.14740/cr1638] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2024] [Accepted: 04/27/2024] [Indexed: 07/13/2024] Open
Abstract
Background Ischemic heart disease (IHD) is a major global health issue and a leading cause of death. This study compares the effectiveness of percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG) in the management of IHD, focusing on their impact on revascularization, myocardial infarction (MI), and post-procedural stroke. This study aimed to evaluate and compare the effectiveness of PCI and CABG in treating IHD based on an exhaustive literature review of the past 5 years, emphasizing recent advancements and outcomes in IHD management. Methods A comprehensive literature review analyzed 32 randomized controlled trials (RCTs) retrieved from databases such as PubMed, Cochrane Library, and Google Scholar. The study specifically assessed the incidences of revascularization, stroke, and MI in patients treated with either PCI or CABG. The comparison between CABG and PCI exclusively focused on lesions with a SYNTAX score exceeding 32. Results Our findings highlight CABG's significant efficacy over PCI in reducing revascularization and MI. The aggregated Mantel-Haenszel (M-H) value for revascularization was 1.85 (95% confidence interval (CI): 1.65 - 2.07), signifying CABG's advantage. Additionally, CABG demonstrated superior performance in diminishing MI occurrences (M-H = 2.71, 95% CI: 1.13 - 6.53). In contrast, PCI was more effective in reducing stroke (M-H = 0.80, 95% CI: 0.60 - 1.10). Conclusion The study confirms CABG's superiority in reducing revascularization and MI in IHD patients, highlighting PCI's effectiveness in reducing stroke risk. These findings underscore the importance of personalized treatment strategies in IHD management and emphasize the need for ongoing research and evidence-based guidelines to aid in treatment selection for IHD patients.
Collapse
Affiliation(s)
- Jordan Llerena-Velastegui
- Pontifical Catholic University of Ecuador, Medical School, Quito, Ecuador
- Center for Health Research in Latin America (CISeAL), Research Center, Quito, Ecuador
| | | | | | - Melany Mejia-Mora
- Pontifical Catholic University of Ecuador, Medical School, Quito, Ecuador
| | | | - Allison Cabrera-Cruz
- Catholic University of Santiago de Guayaquil, Medical School, Guayaquil, Ecuador
| | | | | | | | | |
Collapse
|
4
|
López-Palop R, Carrillo P, Lozano Í. Impact of Sex in the Incidence of Heart Failure in Patients with Chronic Coronary Syndrome. Curr Heart Fail Rep 2024:10.1007/s11897-024-00663-z. [PMID: 38703306 DOI: 10.1007/s11897-024-00663-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/15/2024] [Indexed: 05/06/2024]
Abstract
PURPOSE OF REVIEW This review examines the available evidence concerning the incidence of heart failure in patients with chronic coronary syndrome, with a focus on gender differences. RECENT FINDINGS The incidence of heart failure in the context of chronic coronary syndrome presents conflicting data. Most of the available information stems from studies involving stable patients' post-acute coronary syndrome, revealing a wide range of incidence rates, from less than 3% to over 20%, observed over 5 years of follow-up. Regarding the gender differences in heart failure incidence, there is no consensus about whether women exhibit a higher incidence, particularly in the presence of evidence of obstructive coronary artery disease. However, in cases where obstructive coronary artery disease is absent, women may face a more unfavourable prognosis due to a higher prevalence of microvascular disease and heart failure with preserved ventricular function. The different profile of ischaemic heart disease in women difficult to establish differences in prognosis independently associated with female sex. Targeted investigations are essential to discern the incidence of heart failure in chronic coronary syndrome and explore potential gender-specific associations.
Collapse
Affiliation(s)
- Ramón López-Palop
- Servicio de Cardiología, Hospital Clínico Universitario Virgen de la Arrixaca, Ctra. Murcia-Cartagena s/n. 30120, Murcia, Spain.
| | - Pilar Carrillo
- Servicio de Cardiología, Hospital Clínico Universitario Virgen de la Arrixaca, Ctra. Murcia-Cartagena s/n. 30120, Murcia, Spain
| | - Íñigo Lozano
- Servicio de Cardiología, Hospital Universitario de Cabueñes, Gijón, Spain
- Instituto de Investigación Sanitaria del Principado de Asturias, ISPA, Oviedo, Spain
- Universidad de Oviedo, Oviedo, Spain
| |
Collapse
|
5
|
Khorsandi M, Blumenthal RS, Blaha MJ, Kohli P. The ABCs of the 2023 AHA/ACC/ACCP/ASPC/NLA/PCNA guideline for the management of patients with chronic coronary disease. Clin Cardiol 2024; 47:e24284. [PMID: 38766996 PMCID: PMC11103637 DOI: 10.1002/clc.24284] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2023] [Revised: 04/27/2024] [Accepted: 05/07/2024] [Indexed: 05/22/2024] Open
Abstract
BACKGROUND The 2023 Multisociety Guideline for the Management of Chronic Coronary Disease (CCD) updates recommendations for CCD, formerly known as "stable ischemic heart disease." This condition encompasses a spectrum of coronary vascular pathologies from subclinical to clinical ischemic heart disease. HYPOTHESIS The new "ABC" mnemonic offers clinicians a streamlined framework for applying Class One Recommendations (COR1) and integrating recent updates into CCD management. METHODS A critical analysis of the 2023 CCD guidelines was conducted, with this review highlighting key elements. RESULTS The review outlines crucial changes, including novel recommendations supported by current clinical evidence. The focus is on these developments, clarifying their importance for day-to-day clinical practice. CONCLUSIONS The review encourages a synergistic approach between primary healthcare providers and cardiologists to develop comprehensive strategies for lifestyle modification and medication therapy in CCD care. Furthermore, it suggests that utilizing comprehensive risk assessment tools can refine medical decision-making, ultimately enhancing patient care and clinical outcomes.
Collapse
Affiliation(s)
- Michael Khorsandi
- Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular DiseaseBaltimoreMarylandUSA
| | - Roger S. Blumenthal
- Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular DiseaseBaltimoreMarylandUSA
| | - Michael J. Blaha
- Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular DiseaseBaltimoreMarylandUSA
| | - Payal Kohli
- Cardiology Division, Department of MedicineDuke UniversityDurhamNorth CarolinaUSA
| |
Collapse
|
6
|
da Silveira Maia A, Dos Santos MA. 2023 ACC/AHA Chronic Coronary Disease Guideline - An opportunity to reestablish coronary artery bypass recommendations. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2024:S1553-8389(24)00172-6. [PMID: 38631937 DOI: 10.1016/j.carrev.2024.04.020] [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: 01/25/2024] [Revised: 04/12/2024] [Accepted: 04/13/2024] [Indexed: 04/19/2024]
Abstract
Coronary artery bypass (CABG) has evolved over the decades, supported by scientific evidence from robust studies. The downgrade of the recommendation for CABG in patients with multivessel coronary artery disease proposed by the 2021 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization and the 2023 ACC/AHA Chronic Coronary Disease Guidelines has brought this discussion to the fore, with prestigious cardiothoracic surgery societies such as AATS and STS not supporting these recommendations. The purpose of this article is to broaden this discussion in light of published studies.
Collapse
|
7
|
Gaudino M, Audisio K, Hueb WA, Stone GW, Farkouh ME, Di Franco A, Rahouma M, Serruys PW, Bhatt DL, Biondi Zoccai G, Yusuf S, Girardi LN, Fremes SE, Ruel M, Redfors B. Coronary artery bypass grafting versus medical therapy in patients with stable coronary artery disease: An individual patient data pooled meta-analysis of randomized trials. J Thorac Cardiovasc Surg 2024; 167:1022-1032.e14. [PMID: 35821087 DOI: 10.1016/j.jtcvs.2022.06.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2022] [Revised: 05/16/2022] [Accepted: 06/01/2022] [Indexed: 11/21/2022]
Abstract
OBJECTIVES It is unclear whether coronary artery bypass grafting (CABG) improves survival compared with medical therapy (MT) in patients with stable coronary artery disease (CAD). The aim of this analysis was to perform an individual-patient data-pooled meta-analysis of contemporary randomized controlled trials that compared CABG and MT in patients with stable CAD. METHODS A systematic search was performed in January 2021 to identify randomized controlled trials enrolling adult patients with stable CAD, randomized to CABG or MT. Only trials using at least aspirin, beta-blockers, and statins in the MT arm were included. Individual patient data were obtained from all eligible studies and pooled. The primary outcome was all-cause mortality. RESULTS Four trials involving 2523 patients (1261 CABG; 1262 MT) were included with a median follow-up of 5.6 (4.0-9.2) years. CABG was associated with increased risk of all-cause mortality within 30 days (hazard ratio [HR], 4.81; 95% confidence interval [CI], 1.95-11.83) but subsequent reduction in the long-term risk of death (HR, 0.79; 95% CI, 0.69-0.89). As such, the cumulative 10-year mortality rate was lower in patients treated with CABG compared with MT (45.1% vs 51.7%, respectively; odds ratio, 0.70; 95% CI, 0.58-0.85). Age and race were significant treatment effect modifier (interaction P = .003 for both). CONCLUSIONS In patients with stable CAD, initial allocation to CABG was associated with greater periprocedural risk of death but improved long-term survival compared with MT. The survival advantage for CABG became significant after the fourth postoperative year and was particularly pronounced in younger and non-White patients.
Collapse
Affiliation(s)
- Mario Gaudino
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY.
| | - Katia Audisio
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY
| | - Whady A Hueb
- Heart Institute of the University of São Paulo, São Paulo, Brazil
| | - Gregg W Stone
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Michael E Farkouh
- Peter Munk Cardiac Centre and the Heart and Stroke Richard Lewar Centre, University of Toronto, Toronto, Ontario, Canada
| | - Antonino Di Franco
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY
| | - Mohamed Rahouma
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY
| | - Patrick W Serruys
- International Centre for Circulatory Health, National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | - Deepak L Bhatt
- Brigham and Women's Hospital Heart and Vascular Center and Harvard Medical School, Boston, Mass
| | - Giuseppe Biondi Zoccai
- Department of Medico-Surgical Sciences and Biotechnologies, Sapienza University of Rome, Latina, Italy; Mediterranea Cardiocentro, Napoli, Italy
| | - Salim Yusuf
- Population Health Research Institute, McMaster University, Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - Leonard N Girardi
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY
| | - Stephen E Fremes
- Schulich Heart Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Marc Ruel
- University of Ottawa Heart Institute, University of Ottawa, Ottawa, Ontario, Canada
| | - Bjorn Redfors
- Department of Cardiology, Sahlgrenska University Hospital, Gothenburg, Sweden; Clinical Trials Center, Cardiovascular Research Foundation, New York, NY; NewYork-Presbyterian Hospital/Columbia University Medical Center, New York, NY
| |
Collapse
|
8
|
Jo SH, Kim H, Kim HJ, Lee MH, Seo WW, Kim M, Kim HL. Percutaneous coronary intervention versus medical therapy in stable angina: a matched cohort study. Heart 2024:heartjnl-2023-323541. [PMID: 38286514 DOI: 10.1136/heartjnl-2023-323541] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2023] [Accepted: 12/28/2023] [Indexed: 01/31/2024] Open
Abstract
OBJECTIVE It is uncertain whether percutaneous coronary intervention (PCI) in addition to optimal medical therapy (OMT) can reduce adverse clinical events in the long term as compared with OMT alone in patients with pure stable angina. METHODS We enrolled patients from 2006 to 2010 using the Korean national insurance data. 58 742 patients with pure stable angina with no history of myocardial infarction (MI) nor PCI were candidate, and finally, 5673 patients in the PCI plus OMT group and 5673 in the OMT alone group were selected with 1:1 propensity matching. They were followed up for 9.3 years. RESULTS Primary endpoint, a composite of MI, stroke and cardiac death rate was significantly higher in the PCI group than in the OMT group, 13.5/1000 vs 11.5/1000 person-year with HR of 1.18 (95% CI 1.06 to 1.32, p=0.003). Individual event rate of MI and cardiac death rate was higher in the PCI group than in the OMT group at 9.3 years, 2.9 vs 2.1 (HR 1.38, 95% CI 1.09 to 1.7, p=0.009) and 4.8 vs 3.4/1000 person-year (HR 1.40, 95% CI 1.16 to 1.69, p=0.001), respectively. Revascularisation and total death occurred more in the PCI group as compared with the OMT group, 30.3 vs 8.2 (HR 3.64, 95% CI 3.27 to 4.05, p<0.001) and 13.5 vs 10.6/1000 person-year (HR 1.23, 95% CI 1.12 to 1.40, p<0.001), respectively. In subgroup analysis, the same trend of more event in the PCI group was detected. CONCLUSIONS PCI plus OMT was associated with higher rate of primary endpoint of MI, stroke, cardiac death as compared with OMT alone in patients with pure stable angina at 9.3-year follow-up in large population.
Collapse
Affiliation(s)
- Sang-Ho Jo
- Department of Internal Medicine/ Division of Cardiology, Hallym University Sacred Heart Hospital, Anyang, Korea (the Republic of)
| | - Hoseob Kim
- Department of Data Science, Hanmi Pharmaceuticals Co., Ltd, Seoul, Korea (the Republic of)
| | - Hyun-Jin Kim
- Division of Cardiology, Department of Internal Medicine, Hanyang University College of Medicine, Seoul, Korea (the Republic of)
| | - Min-Ho Lee
- Division of Cardiology, Department of Internal Medicine, Soonchunhyang University Seoul Hospital, Seoul, Korea (the Republic of)
| | - Won-Woo Seo
- Department of Internal Medicine, Department of Internal Medicine, Kangdong Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Korea (the Republic of)
| | - Mina Kim
- Department of Data Science, Hanmi Pharmaceuticals Co., Ltd, Seoul, Korea (the Republic of)
| | - Hack-Lyoung Kim
- Division of Cardiology, Department of Internal Medicine, Seoul Metropolitan Government-Seoul National University Boramae Medical Center, Seoul, Korea (the Republic of)
| |
Collapse
|
9
|
Heutinck JM, de Koning IA, Vromen T, Thijssen DHJ, Kemps HMC. Exercise-based cardiac rehabilitation in stable angina pectoris: a narrative review on current evidence and underlying physiological mechanisms. Neth Heart J 2024; 32:23-30. [PMID: 37982981 PMCID: PMC10781904 DOI: 10.1007/s12471-023-01830-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/10/2023] [Indexed: 11/21/2023] Open
Abstract
Stable angina pectoris (SAP) is a prevalent condition characterised by a high disease burden. Based on recent evidence, the need for revascularisation in addition to optimal medical treatment to reduce mortality and re-events is heavily debated. These observations may be explained by the fact that revascularisation is targeted at the local flow-limiting coronary artery lesion, while the aetiology of SAP relates to the systemic, inflammatory process of atherosclerosis, causing generalised vascular dysfunction throughout the entire vascular system. Moreover, cardiovascular events are not solely caused by obstructive plaques but are also associated with plaque burden and high-risk plaque features. Therefore, to reduce the risk of cardiovascular events and angina, and thereby improve quality of life, alternative therapeutic approaches to revascularisation should be considered, preferably targeting the cardiovascular system as a whole with a physiological approach. Exercise-based cardiac rehabilitation fits this description and is a promising strategy as a first-line treatment in addition to optimal medical treatment. In this review, we discuss the role of exercise-based cardiac rehabilitation in SAP in relation to the underlying physiological mechanisms, we summarise the existing evidence and highlight future directions.
Collapse
Affiliation(s)
- Joyce M Heutinck
- Department of Medical BioSciences, Radboud University Medical Center, Nijmegen, The Netherlands.
- Department of Industrial Design, Eindhoven University of Technology, Eindhoven, The Netherlands.
| | - Iris A de Koning
- Department of Medical BioSciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Tom Vromen
- Department of Cardiology, Maxima Medical Centre, Veldhoven, The Netherlands
| | - Dick H J Thijssen
- Department of Medical BioSciences, Radboud University Medical Center, Nijmegen, The Netherlands
- Research Institute for Sport and Exercise Sciences, Liverpool John Moores University, Liverpool, UK
| | - Hareld M C Kemps
- Department of Industrial Design, Eindhoven University of Technology, Eindhoven, The Netherlands
- Department of Cardiology, Maxima Medical Centre, Veldhoven, The Netherlands
| |
Collapse
|
10
|
Golukhova EZ, Slivneva IV, Kozlova OS, Berdibekov BS, Skopin II, Merzlyakov VY, Baichurin RK, Sigaev IY, Keren MA, Alshibaya MD, Marapov DI, Arzumanyan MA. Treatment Strategies for Chronic Coronary Heart Disease with Left Ventricular Systolic Dysfunction or Preserved Ejection Fraction-A Systematic Review and Meta-Analysis. PATHOPHYSIOLOGY 2023; 30:640-658. [PMID: 38133147 PMCID: PMC10747738 DOI: 10.3390/pathophysiology30040046] [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: 11/22/2023] [Revised: 12/11/2023] [Accepted: 12/13/2023] [Indexed: 12/23/2023] Open
Abstract
In this meta-analysis, we examine the advantages of invasive strategies for patients diagnosed with chronic coronary heart disease (CHD) and preserved left ventricular (LV) function, as well as those with significant LV systolic dysfunction (LV ejection fraction (EF) < 45%). MATERIAL AND METHODS We conducted a systematic search to identify all randomized trials directly comparing invasive strategies with optimal medical therapy (OMT) in patients diagnosed with chronic CHD. Data from these trials were pooled using a random-effects meta-analysis. The primary outcome assessed was the all-cause mortality, while secondary endpoints included cardiovascular (CV) death, stroke, myocardial infarction (MI), and unplanned revascularization. This study was designed to assess the benefits of both invasive strategies and OMT in patients with preserved LV function and in those with LV systolic dysfunction. The statistical analysis of the data was conducted using the Review Manager (RevMan) software, version 5.4.1 (The Cochrane Collaboration, 2020). RESULTS Twelve randomized studies enrolling 13,912 patients were included in the final analysis. Among the patients with chronic CHD and preserved LV systolic function, revascularization did not demonstrate a reduction in all-cause mortality (8.52% vs. 8.45%, p = 0.45), CV death (3.41% vs. 3.62%, p = 0.08), or the incidence of MI (9.88% vs. 10.49%, p = 0.47). However, the need for unplanned myocardial revascularization was significantly lower in the group following the initial invasive approach compared to patients undergoing OMT (14.75% vs. 25.72%, p < 0.001). In contrast, the invasive strategy emerged as the preferred treatment modality for patients with ischemic LV systolic dysfunction. This approach demonstrated lower rates of all-cause mortality (40.61% vs. 46.52%, p = 0.004), CV death (28.75% vs. 35.82%, p = 0.0004), and MI (8.19% vs. 10.8%, p = 0.03). CONCLUSIONS In individuals diagnosed with chronic CHD and preserved LV EF, the initial invasive approach did not demonstrate a clinical advantage over OMT. Conversely, in patients with ischemic LV systolic dysfunction, myocardial revascularization was found to reduce the risks of CV events and enhance the overall outcomes. These findings hold significant clinical relevance for optimizing treatment strategies in patients with chronic CHD, contingent upon myocardial contractility status.
Collapse
Affiliation(s)
| | - Inessa Viktorovna Slivneva
- Department of Cardiovascular and Comorbid Pathology, A.N. Bakulev National Medical Scientific Center for Cardiovascular Surgery, 121552 Moscow, Russia; (O.S.K.); (R.K.B.); (M.A.A.)
| | - Olga Sergeevna Kozlova
- Department of Cardiovascular and Comorbid Pathology, A.N. Bakulev National Medical Scientific Center for Cardiovascular Surgery, 121552 Moscow, Russia; (O.S.K.); (R.K.B.); (M.A.A.)
| | - Bektur Shukurbekovich Berdibekov
- Department of Non-Invasive Arrhythmology and Surgical Treatment of Combined Pathology, A.N. Bakulev National Medical Scientific Center for Cardiovascular Surgery, 121552 Moscow, Russia;
| | - Ivan Ivanovich Skopin
- Department of Reconstructive Surgery of Heart Valves and Coronary Arteries, A.N. Bakulev National Medical Research Center for Cardiovascular Surgery, 121552 Moscow, Russia;
| | - Vadim Yuryevich Merzlyakov
- Department of Surgical Treatment of Ischemic Heart Disease and Minimally Invasive Coronary Surgery, A.N. Bakulev National Medical Research Center for Cardiovascular Surgery, 121552 Moscow, Russia;
| | - Renat Kamilyevich Baichurin
- Department of Cardiovascular and Comorbid Pathology, A.N. Bakulev National Medical Scientific Center for Cardiovascular Surgery, 121552 Moscow, Russia; (O.S.K.); (R.K.B.); (M.A.A.)
- Department of Surgical Treatment of Ischemic Heart Disease and Minimally Invasive Coronary Surgery, A.N. Bakulev National Medical Research Center for Cardiovascular Surgery, 121552 Moscow, Russia;
| | - Igor Yuryevich Sigaev
- Department of Surgical Treatment of Coronary and Great Arteries Combined Diseases, A.N. Bakulev National Medical Scientific Center for Cardiovascular Surgery, 121552 Moscow, Russia; (I.Y.S.); (M.A.K.)
| | - Milena Abrekovna Keren
- Department of Surgical Treatment of Coronary and Great Arteries Combined Diseases, A.N. Bakulev National Medical Scientific Center for Cardiovascular Surgery, 121552 Moscow, Russia; (I.Y.S.); (M.A.K.)
| | - Mikhail Durmishkhanovich Alshibaya
- Department of Surgical Treatment of Ischemic Heart Disease, A.N. Bakulev National Medical Scientific Center for Cardiovascular Surgery, 121552 Moscow, Russia;
| | - Damir Ildarovich Marapov
- Department of Public Health, Economics and Health Care Management, Kazan State Medical Academy—Branch Campus of the Federal State Budgetary Educational Institution of Further Professional Education, Russian Medical Academy of Continuous Professional Education, 420012 Kazan, Russia;
| | - Milena Artemovna Arzumanyan
- Department of Cardiovascular and Comorbid Pathology, A.N. Bakulev National Medical Scientific Center for Cardiovascular Surgery, 121552 Moscow, Russia; (O.S.K.); (R.K.B.); (M.A.A.)
| |
Collapse
|
11
|
Clerc OF, Frey SM, Honegger U, Amrein MLF, Caobelli F, Haaf P, Zellweger MJ. Coronary artery calcium score and pre-test probabilities as gatekeepers to predict and rule out perfusion defects in positron emission tomography. J Nucl Cardiol 2023; 30:2559-2573. [PMID: 37415007 PMCID: PMC10682222 DOI: 10.1007/s12350-023-03322-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2023] [Accepted: 06/02/2023] [Indexed: 07/08/2023]
Abstract
BACKGROUND Little is known about the gatekeeper performance of coronary artery calcium score (CACS) before myocardial perfusion positron emission tomography (PET), compared with updated pre-test probabilities from American and European guidelines (pre-test-AHA/ACC, pre-test-ESC). METHODS We enrolled participants without known coronary artery disease undergoing CACS and Rubidium-82 PET. Abnormal perfusion was defined as summed stress score ≥ 4. Using Bayes' formula, pre-test probabilities and CACS were combined into post-test probabilities. RESULTS We included 2050 participants (54% male, mean age 64.6 years) with median CACS 62 (IQR 0-380), pre-test-ESC 17% (11-26), pre-test-AHA/ACC 27% (16-44), and abnormal perfusion in 437 participants (21%). To predict abnormal perfusion, area under the curve of CACS was 0.81, pre-test-AHA/ACC 0.68, pre-test-ESC 0.69, post-test-AHA/ACC 0.80, and post-test-ESC 0.81 (P < 0.001 for CACS vs. each pre-test, and each post-test vs. pre-test). CACS = 0 had 97% negative predictive value (NPV), pre-test-AHA/ACC ≤ 5% 100%, pre-test-ESC ≤ 5% 98%, post-test-AHA/ACC ≤ 5% 98%, and post-test-ESC ≤ 5% 96%. Among participants, 26% had CACS = 0, 2% pre-test-AHA/ACC ≤ 5%, 7% pre-test-ESC ≤ 5%, 23% post-test-AHA/ACC ≤ 5%, and 33% post-test-ESC ≤ 5% (all P < 0.001). CONCLUSIONS CACS and post-test probabilities are excellent predictors of abnormal perfusion and can rule it out with very high NPV in a substantial proportion of participants. CACS and post-test probabilities may be used as gatekeepers before advanced imaging. Coronary artery calcium score (CACS) predicted abnormal perfusion (SSS ≥ 4) in myocardial positron emission tomography (PET) better than pre-test probabilities of coronary artery disease (CAD), while pre-test-AHA/ACC and pre-test-ESC performed similarly (left). Using Bayes' formula, pre-test-AHA/ACC or pre-test-ESC were combined with CACS into post-test probabilities (middle). This calculation reclassified a substantial proportion of participants to low probability of CAD (0-5%), not needing further imaging, as shown for AHA/ACC probabilities (2% with pre-test-AHA/ACC to 23% with post-test-AHA/ACC, P < 0.001, right). Very few participants with abnormal perfusion were classified under pre-test or post-test probabilities 0-5%, or under CACS 0. AUC: area under the curve. Pre-test-AHA/ACC: Pre-test probability of the American Heart Association/American College of Cardiology. Post-test-AHA/ACC: Post-test probability combining pre-test-AHA/ACC and CACS. Pre-test-ESC: Pre-test probability of the European Society of Cardiology. SSS: Summed stress score.
Collapse
Affiliation(s)
- Olivier F Clerc
- Department of Cardiology, University Hospital Basel, University of Basel, Petersgraben 4, 4031, Basel, Switzerland
- Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Basel, Switzerland
| | - Simon M Frey
- Department of Cardiology, University Hospital Basel, University of Basel, Petersgraben 4, 4031, Basel, Switzerland
- Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Basel, Switzerland
| | - Ursina Honegger
- Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Basel, Switzerland
| | - Melissa L F Amrein
- Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Basel, Switzerland
| | - Federico Caobelli
- Department of Nuclear Medicine, Clinic of Radiology and Nuclear Medicine, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Philip Haaf
- Department of Cardiology, University Hospital Basel, University of Basel, Petersgraben 4, 4031, Basel, Switzerland
- Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Basel, Switzerland
| | - Michael J Zellweger
- Department of Cardiology, University Hospital Basel, University of Basel, Petersgraben 4, 4031, Basel, Switzerland.
- Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Basel, Switzerland.
| |
Collapse
|
12
|
Chen Y, Zhong J, Chen L, Hong R, Yan Y, Chen L, Chen Q, Luo Y. Effects of percutaneous coronary intervention and diabetes mellitus on short- and long-term prognosis assessed by the three-vessel quantitative flow ratio. Diabetes Res Clin Pract 2023; 206:111013. [PMID: 37972858 DOI: 10.1016/j.diabres.2023.111013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2023] [Revised: 10/30/2023] [Accepted: 11/13/2023] [Indexed: 11/19/2023]
Abstract
AIMS We aimed to investigate the impact of percutaneous coronary intervention (PCI) and diabetes mellitus (DM) on short- and long-term prognosis in patients with coronary artery disease using three-vessel quantitative flow ratio (3 V-QFR) assessment. METHODS A retrospective analysis of 2440 vessels in 1181 patients who underwent PCI was performed. The patients were categorized according to the presence or absence of DM and the median 3 V-QFR. The primary outcome was the occurrence of major adverse cardiac events (MACE), defined as a combination of cardiovascular death, myocardial infarction, and ischemia-driven revascularization, over a 5-year period. RESULTS The pre-PCI and post-PCI 3 V-QFR values for the entire population were 2.37 (2.04-2.56) and 2.94 (2.82-3.00), respectively. Landmark analysis showed that the incidence of MACE was comparable among all groups within the first year (log-rank p = 0.088). Over the course of 2 years, the incidence of MACE was higher in both groups with a post-PCI 3 V-QFR < 2.94 (log-rank p < 0.001). However, from 2 to 5 years, patients with DM had higher rates of MACE (log-rank p = 0.013). CONCLUSIONS In the short term, a low post-PCI 3 V-QFR is a predictor of high risk for MACE. However, in the long term, DM emerges as the dominant risk factor.
Collapse
Affiliation(s)
- Yuxiang Chen
- Department of Cardiology, Fujian Medical University Union Hospital, No. 29 Xin Quan Road, Fuzhou, Fujian 350001, PR China; Fujian Institute of Coronary Heart Disease, Fuzhou, Fujian 350001, PR China; Fujian Heart Medical Center, Fuzhou, Fujian 350001, PR China.
| | - Jiaxin Zhong
- Department of Cardiology, Fujian Medical University Union Hospital, No. 29 Xin Quan Road, Fuzhou, Fujian 350001, PR China; Fujian Institute of Coronary Heart Disease, Fuzhou, Fujian 350001, PR China; Fujian Heart Medical Center, Fuzhou, Fujian 350001, PR China.
| | - Lihua Chen
- Department of Cardiology, Fujian Medical University Union Hospital, No. 29 Xin Quan Road, Fuzhou, Fujian 350001, PR China; Fujian Institute of Coronary Heart Disease, Fuzhou, Fujian 350001, PR China; Fujian Heart Medical Center, Fuzhou, Fujian 350001, PR China.
| | - Ruijin Hong
- Department of Cardiology, Fujian Medical University Union Hospital, No. 29 Xin Quan Road, Fuzhou, Fujian 350001, PR China; Fujian Institute of Coronary Heart Disease, Fuzhou, Fujian 350001, PR China; Fujian Heart Medical Center, Fuzhou, Fujian 350001, PR China.
| | - Yuanming Yan
- Department of Cardiology, Fujian Medical University Union Hospital, No. 29 Xin Quan Road, Fuzhou, Fujian 350001, PR China; Fujian Institute of Coronary Heart Disease, Fuzhou, Fujian 350001, PR China; Fujian Heart Medical Center, Fuzhou, Fujian 350001, PR China.
| | - Lianglong Chen
- Department of Cardiology, Fujian Medical University Union Hospital, No. 29 Xin Quan Road, Fuzhou, Fujian 350001, PR China; Fujian Institute of Coronary Heart Disease, Fuzhou, Fujian 350001, PR China; Fujian Heart Medical Center, Fuzhou, Fujian 350001, PR China.
| | - Qin Chen
- Department of Cardiology, Fujian Medical University Union Hospital, No. 29 Xin Quan Road, Fuzhou, Fujian 350001, PR China; Fujian Institute of Coronary Heart Disease, Fuzhou, Fujian 350001, PR China; Fujian Heart Medical Center, Fuzhou, Fujian 350001, PR China.
| | - Yukun Luo
- Department of Cardiology, Fujian Medical University Union Hospital, No. 29 Xin Quan Road, Fuzhou, Fujian 350001, PR China; Fujian Institute of Coronary Heart Disease, Fuzhou, Fujian 350001, PR China; Fujian Heart Medical Center, Fuzhou, Fujian 350001, PR China.
| |
Collapse
|
13
|
Piccolo R, Leone A, Avvedimento M, Simonetti F, Ippolito D, Angellotti D, Verde N, Manzi L, Cirillo P, Serafino LD, Fortunato G, Franzone A, Esposito G. Impact of biomarker type on periprocedural myocardial infarction in patients undergoing elective PCI. EUROPEAN HEART JOURNAL. QUALITY OF CARE & CLINICAL OUTCOMES 2023; 9:680-690. [PMID: 36385164 DOI: 10.1093/ehjqcco/qcac075] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/16/2022] [Revised: 10/30/2022] [Accepted: 11/15/2022] [Indexed: 11/08/2023]
Abstract
BACKGROUND Periprocedural myocardial infarction (MI) according to the Society for Cardiovascular Angiography and Interventions (SCAI) criteria has prognostic relevance among patients undergoing percutaneous coronary intervention (PCI). However, it is unclear whether the type of cardiac biomarker used for the diagnosis of periprocedural MI plays a role in terms of event frequency and outcomes. OBJECTIVES To compare the characteristics of SCAI periprocedural MI based on creatine kinase-myocardial band fraction (CK-MB) vs. high-sensitivity cardiac troponin (hs-cTn) in patients undergoing elective PCI. METHODS AND RESULTS Between 2017 and 2021, periprocedural MI was assessed in a prospective study. The primary clinical outcome of interest was all-cause death at 1-year follow-up. A total of 1010 patients undergoing elective PCI were included. SCAI periprocedural MI based on CK-MB vs. hs-cTnI occurred in 1.8 and 13.5% of patients, respectively. hs-cTnI periprocedural MI in the absence of concomitant CK-MB criteria was associated with lower rates of ancillary criteria, including angiographic, ECG, and cardiac imaging criteria. At 1-year follow-up, periprocedural MI defined by CK-MB (adjusted hazard ratio, HR, 4.27, 95% confidence intervals, CI, 1.23-14.8; P = 0.022) but not hs-cTnI (adjusted HR 2.04, 95% CI 0.94-4.45; P = 0.072) was associated with a higher risk of all-cause death. Hs-cTnI periprocedural MI was not predictive of death unless accompanied by CK-MB criteria (adjusted HR 4.64, 95% CI 1.32-16.31; P = 0.017). CONCLUSION In the setting of elective PCI, using hs-cTn instead of CK-MB resulted in a substantial increase in SCAI periprocedural MI events, which were not prognostically relevant in the absence of concurrent CK-MB elevations.
Collapse
Affiliation(s)
- Raffaele Piccolo
- Department of Advanced Biomedical Sciences, University of Naples Federico II, 80131 Naples, Italy
| | - Attilio Leone
- Department of Advanced Biomedical Sciences, University of Naples Federico II, 80131 Naples, Italy
| | - Marisa Avvedimento
- Department of Advanced Biomedical Sciences, University of Naples Federico II, 80131 Naples, Italy
| | - Fiorenzo Simonetti
- Department of Advanced Biomedical Sciences, University of Naples Federico II, 80131 Naples, Italy
| | - Domenico Ippolito
- Department of Advanced Biomedical Sciences, University of Naples Federico II, 80131 Naples, Italy
| | - Domenico Angellotti
- Department of Advanced Biomedical Sciences, University of Naples Federico II, 80131 Naples, Italy
| | - Nicola Verde
- Department of Advanced Biomedical Sciences, University of Naples Federico II, 80131 Naples, Italy
| | - Lina Manzi
- Department of Advanced Biomedical Sciences, University of Naples Federico II, 80131 Naples, Italy
| | - Plinio Cirillo
- Department of Advanced Biomedical Sciences, University of Naples Federico II, 80131 Naples, Italy
| | - Luigi Di Serafino
- Department of Advanced Biomedical Sciences, University of Naples Federico II, 80131 Naples, Italy
| | - Giuliana Fortunato
- Department of Molecular Medicine and Medical Biotechnology, University of Naples Federico II and CEINGE S.C.a r.l. Advanced Biotechnology, 80131 Naples, Italy
| | - Anna Franzone
- Department of Advanced Biomedical Sciences, University of Naples Federico II, 80131 Naples, Italy
| | - Giovanni Esposito
- Department of Advanced Biomedical Sciences, University of Naples Federico II, 80131 Naples, Italy
| |
Collapse
|
14
|
Hirao Y, Seki T, Watanabe N, Matoba S. Health-Related Quality of Life After Percutaneous Coronary Intervention for Stable Ischemic Heart Disease: A Systematic Review and Meta-analysis. Can J Cardiol 2023; 39:1539-1548. [PMID: 37422259 DOI: 10.1016/j.cjca.2023.06.429] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Revised: 06/07/2023] [Accepted: 06/30/2023] [Indexed: 07/10/2023] Open
Abstract
BACKGROUND There has been no meta-analysis of whether percutaneous coronary intervention (PCI) with optimal medical therapy (OMT) improves health-related quality of life (HRQL) compared with OMT alone in patients with stable ischemic heart disease (SIHD). METHODS We searched MEDLINE, Cochrane Central Registry of Controlled Trials, Embase, ClinicalTrials.gov, and International Clinical Trials Registry Platform in November 2022. We included randomized controlled trials (RCTs) that compared PCI with OMT vs OMT alone with HRQL in patients with SIHD. The primary outcome was the aggregated physical HRQL, including physical functioning using the Short Form (SF)-36 or RAND-36, physical limitation using the Seattle Angina Questionnaire (SAQ) or SAQ-7, McMaster Health Index Questionnaire, and Duke Activity Status Index within 6 months. Data were analyzed using a random effects model when substantial heterogeneity was identified or a fixed effect model otherwise. RESULTS Among 14 systematically reviewed RCTs, 12 RCTs with 12,238 patients were meta-analyzed. Only 1 trial had a low risk of bias in all domains. PCI with OMT improved aggregated physical HRQL (standardized mean difference, 0.16; 95% confidence interval [CI], 0.1-0.23; P < 0.0001) at 6 months. Also, PCI with OMT improved physical functioning on the SF-36/RAND-36 (mean difference 3.65; 95% CI, 1.88-5.41) and physical limitation on the SAQ/SAQ-7 (mean difference, 3.09; 95% CI, 0.93-5.24) compared with OMT alone at 6 months. However, all of the aggregated physical HRQL domains were classified into small effects, and no HRQL domain exceeded the prespecified minimal clinically important difference. CONCLUSIONS These findings showed that PCI with OMT improved HRQL compared with OMT alone in patients with SIHD, but the benefit was not large.
Collapse
Affiliation(s)
- Yu Hirao
- Department of Cardiovascular Medicine, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Tomotsugu Seki
- Department of Cardiovascular Medicine, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan.
| | - Norio Watanabe
- Department of Psychiatry, Soseikai General Hospital, Kyoto, Japan
| | - Satoaki Matoba
- Department of Cardiovascular Medicine, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| |
Collapse
|
15
|
Byrne RA, Fremes S, Capodanno D, Czerny M, Doenst T, Emberson JR, Falk V, Gaudino M, McMurray JJV, Mehran R, Milojevic M, Sousa Uva M. 2022 Joint ESC/EACTS review of the 2018 guideline recommendations on the revascularization of left main coronary artery disease in patients at low surgical risk and anatomy suitable for PCI or CABG. Eur Heart J 2023; 44:4310-4320. [PMID: 37632756 DOI: 10.1093/eurheartj/ehad476] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Revised: 06/06/2023] [Accepted: 07/15/2023] [Indexed: 08/28/2023] Open
Abstract
In October 2021, the European Society of Cardiology (ESC) and the European Association for Cardio-Thoracic Surgery (EACTS) jointly agreed to establish a Task Force (TF) to review recommendations of the 2018 ESC/EACTS Guidelines on myocardial revascularization as they apply to patients with left main (LM) disease with low-to-intermediate SYNTAX score (0-32). This followed the withdrawal of support by the EACTS in 2019 for the recommendations about the management of LM disease of the previous guideline. The TF was asked to review all new relevant data since the 2018 guidelines including updated aggregated data from the four randomized trials comparing percutaneous coronary intervention (PCI) with drug-eluting stents vs. coronary artery bypass grafting (CABG) in patients with LM disease. This document represents a summary of the work of the TF; suggested updated recommendations for the choice of revascularization modality in patients undergoing myocardial revascularization for LM disease are included. In stable patients with an indication for revascularization for LM disease, with coronary anatomy suitable for both procedures and a low predicted surgical mortality, the TF concludes that both treatment options are clinically reasonable based on patient preference, available expertise, and local operator volumes. The suggested recommendations for revascularization with CABG are Class I, Level of Evidence A. The recommendations for PCI are Class IIa, Level of Evidence A. The TF recognized several important gaps in knowledge related to revascularization in patients with LM disease and recognizes that aggregated data from the four randomized trials were still only large enough to exclude large differences in mortality.
Collapse
Affiliation(s)
- Robert A Byrne
- Department of Cardiology and Cardiovascular Research Institute (CVRI) Dublin, Mater Private Network, 73 Eccles St, Dublin D07 KWR1, Ireland
- School of Pharmacy and Biomolecular Sciences, RCSI University of Medicine and Health Sciences, 123 St Stephen's Green, D02 YN77 Dublin, Ireland
| | - Stephen Fremes
- Division of Cardiac Surgery, Schulich Heart Program, Sunnybrook Health Sciences Centre, 2075 Bayview Ave, Suite H405, M4N3M5 Toronto, Canada
- Department of Surgery, University of Toronto, Toronto, Canada
| | - Davide Capodanno
- Cardio-Thoracic-Vascular and Transplant Department, Azienda Ospedaliero-Universitaria Policlinico 'Gaspare Rodolico-San Marco', University of Catania, Catania, Italy
| | - Martin Czerny
- Clinic for Cardiovascular Surgery, University Heart Center Freiburg, Bad Krozingen, Germany
- Faculty of Medicine, Albert-Ludwigs-University Freiburg, Freiburg, Germany
| | - Torsten Doenst
- Department of Cardiothoracic Surgery, University Hospital Jena, Friedrich-Schiller-University Jena, Jena, Germany
| | - Jonathan R Emberson
- Medical Research Council Population Health Research Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Volkmar Falk
- Department of Cardiothoracic and Vascular Surgery, Deutsches Herzzentrum Berlin, Berlin, Germany
- Department of Cardiovascular Surgery, Charité Universitätsmedizin Berlin, Berlin, Germany
- German Centre for Cardiovascular Research, DZHK, Partner Site Berlin, Berlin, Germany
- Department of Health Science and Technology, ETH Zurich, Zürich, Switzerland
| | - Mario Gaudino
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY, USA
| | - John J V McMurray
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow, UK
| | - Roxana Mehran
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Milan Milojevic
- Department of Cardiac Surgery and Cardiovascular Research, Dedinje Cardiovascular Institute, Belgrade, Serbia
- Department of Cardiothoracic Surgery, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Miguel Sousa Uva
- Department of Cardiac Surgery, Hospital Santa Cruz, Carnaxide, Portugal
- Department of Physiology and Cardiac Surgery, Porto University Medical School, Porto, Portugal
| |
Collapse
|
16
|
Joodi G, Palimar S, Press MC. Percutaneous Coronary Interventions in Women. Curr Atheroscler Rep 2023; 25:829-837. [PMID: 37815649 PMCID: PMC10618306 DOI: 10.1007/s11883-023-01150-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/06/2023] [Indexed: 10/11/2023]
Abstract
PURPOSEOF REVIEW Cardiovascular disease is the leading cause of morbidity and mortality among women globally. Numerous studies show ongoing disparities in diagnosis, management, and outcomes of ischemic heart disease in women compared to men. We aim to review the factors contributing to sex-based differential outcomes of percutaneous coronary interventions in women. RECENT FINDINGS Hormonal influence on coronary arteries and progression of atherosclerosis in women results in distinct coronary plaque characteristics and unique pathological process such as spontaneous coronary artery dissection and myocardial infarction with non-obstructive coronary arteries. During the presentation of acute coronary syndromes, women are older and have higher burden of comorbidities, with higher short- and long-term mortality. Awareness of differences in vascular biology and unique risk factors for cardiovascular disease in women is essential for sustained improvement in cardiovascular mortality. Better representation of women in trials is crucial to address the gaps in knowledge and allow for individualized treatment approaches in women.
Collapse
Affiliation(s)
- Golsa Joodi
- Department of Medicine, Division of Cardiology, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Sristi Palimar
- Institute for Society and Genetics, UCLA, Los Angeles, CA, USA
| | - Marcella Calfon Press
- Department of Medicine, Division of Cardiology, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA.
| |
Collapse
|
17
|
Soca G, Martínez A, Gomes WJ, Solano JG, Almeida R, Ibañez MA, Marin-Cuartas M, Hurtado G, Dayan V. The South American Society of Cardiology (SSC) and the Latin American Association of Cardiac and Endovascular Surgery (LACES) Statement on the 2021 ACC/AHA/SCAI Guidelines for Coronary Artery Revascularization. Braz J Cardiovasc Surg 2023; 38:e20230119. [PMID: 37796841 PMCID: PMC10548594 DOI: 10.21470/1678-9741-2023-0119] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2023] [Accepted: 04/24/2023] [Indexed: 10/07/2023] Open
Affiliation(s)
- Gerardo Soca
- Centro Cardiovascular Universitario, Universidad de la Republica
del Uruguay, Montevideo, Uruguay
| | - Alejandro Martínez
- Division of Cardiovascular Diseases, Pontifícia Universidad
Católica de Chile, Santiago, Chile
| | - Walter J. Gomes
- Cardiovascular Surgery Discipline, Hospital São Paulo,
Escola Paulista de Medicina, Universidade Federal de São Paulo, São
Paulo, São Paulo, Brazil
| | | | - Rui Almeida
- Faculdade de Medicina, Centro Universitário
Fundação Assis Gurgacz, Cascavel, Paraná, Brazil
| | - Maria Alejandra Ibañez
- Cardioayuda Ltda. y Sociedad Colombiana de Cardiología y
Cirugía Cardiovascular, Bogotá, Colombia
| | - Mateo Marin-Cuartas
- University Clinic for Cardiac Surgery, Leipzig Heart Center,
Leipzig, Germany
| | - Graciela Hurtado
- Seguro Integral de Salud (SINEC) – Seguridad Social y Unidad de
Diagnóstico Médico (UDIME), Santa Cruz de la Sierra, Bolivia
| | - Victor Dayan
- Centro Cardiovascular Universitario, Universidad de la Republica
del Uruguay, Montevideo, Uruguay
| |
Collapse
|
18
|
Bakaeen FG, Ruel M, Calhoon JH, Girardi LN, Guyton R, Hui D, Kelly RF, MacGillivray TE, Malaisrie SC, Moon MR, Sabik JF, Smith PK, Svensson LG, Szeto WY. STS/AATS-Endorsed Rebuttal to 2023 ACC/AHA Chronic Coronary Disease Guideline: A Missed Opportunity to Present Accurate and Comprehensive Revascularization Recommendations. Ann Thorac Surg 2023; 116:675-678. [PMID: 37530679 DOI: 10.1016/j.athoracsur.2023.02.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2023] [Accepted: 02/05/2023] [Indexed: 08/03/2023]
Affiliation(s)
- Faisal G Bakaeen
- Coronary Center, Department of Thoracic and Cardiovascular Surgery, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio.
| | - Marc Ruel
- Division of Cardiac Surgery, University of Ottawa, Ottawa, Ontario, Canada
| | - John H Calhoon
- Department of Cardiothoracic Surgery, University of Texas Health Science Center, San Antonio, Texas
| | - Leonard N Girardi
- Department of Cardiothoracic Surgery, NewYork-Presbyterian/Weil Cornell Medical Center, New York, New York
| | - Robert Guyton
- Cardiothoracic Surgery, The Emory Clinic, Inc, Atlanta, Georgia
| | - Dawn Hui
- Department of Cardiothoracic Surgery, University of Texas Health Science Center, San Antonio, Texas
| | - Rosemary F Kelly
- Division of Cardiothoracic Surgery, University of Minnesota, Minneapolis, Minnesota
| | - Thomas E MacGillivray
- Department of Cardiac Surgery, MedStar Heart and Vascular Institute, Washington Hospital Center, Washington, DC
| | | | - Marc R Moon
- Division of Cardiothoracic Surgery, Baylor College of Medicine, Houston, Texas
| | - Joseph F Sabik
- Department of Surgery, University Hospitals Cleveland Medical Center, Case Western Reserve University, Cleveland, Ohio
| | - Peter K Smith
- Department of Cardiothoracic Surgery, Duke University, Durham, North Carolina
| | - Lars G Svensson
- Coronary Center, Department of Thoracic and Cardiovascular Surgery, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Wilson Y Szeto
- Department of Cardiothoracic Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| |
Collapse
|
19
|
Bakaeen FG, Ruel M, Calhoon JH, Girardi LN, Guyton R, Hui D, Kelly RF, MacGillivray TE, Malaisrie SC, Moon MR, Sabik JF, Smith PK, Svensson LG, Szeto WY. STS/AATS-endorsed rebuttal to 2023 ACC/AHA Chronic Coronary Disease Guideline: A missed opportunity to present accurate and comprehensive revascularization recommendations. J Thorac Cardiovasc Surg 2023; 166:1115-1118. [PMID: 37530691 DOI: 10.1016/j.jtcvs.2023.03.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2023] [Accepted: 02/05/2023] [Indexed: 08/03/2023]
Affiliation(s)
- Faisal G Bakaeen
- Coronary Center, Department of Thoracic and Cardiovascular Surgery, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio.
| | - Marc Ruel
- Division of Cardiac Surgery, University of Ottawa, Ottawa, Ontario, Canada
| | - John H Calhoon
- Department of Cardiothoracic Surgery, University of Texas Health Science Center, San Antonio, Tex
| | - Leonard N Girardi
- Department of Cardiothoracic Surgery, NewYork-Presbyterian/Weil Cornell Medical Center, New York, NY
| | - Robert Guyton
- Cardiothoracic Surgery, The Emory Clinic, Inc, Atlanta, Ga
| | - Dawn Hui
- Department of Cardiothoracic Surgery, University of Texas Health Science Center, San Antonio, Tex
| | - Rosemary F Kelly
- Division of Cardiothoracic Surgery, University of Minnesota, Minneapolis, Minn
| | - Thomas E MacGillivray
- Department of Cardiac Surgery, MedStar Heart and Vascular Institute, Washington Hospital Center, Washington, DC
| | | | - Marc R Moon
- Division of Cardiothoracic Surgery, Baylor College of Medicine, Houston, Tex
| | - Joseph F Sabik
- Department of Surgery, University Hospitals Cleveland Medical Center, Case Western Reserve University, Cleveland, Ohio
| | - Peter K Smith
- Department of Cardiothoracic Surgery, Duke University, Durham, NC
| | - Lars G Svensson
- Coronary Center, Department of Thoracic and Cardiovascular Surgery, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Wilson Y Szeto
- Department of Cardiothoracic Surgery, University of Pennsylvania, Philadelphia, Pa
| |
Collapse
|
20
|
Benenati S, De Maria GL, Kotronias R, Porto I, Banning AP. Why percutaneous revascularisation might not reduce the risk of myocardial infarction and mortality in patients with stable CAD? Open Heart 2023; 10:e002343. [PMID: 37890892 PMCID: PMC10619108 DOI: 10.1136/openhrt-2023-002343] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2023] [Accepted: 08/07/2023] [Indexed: 10/29/2023] Open
Abstract
Percutaneous coronary intervention (PCI) is widely adopted to treat chronic coronary artery disease. Numerous randomised trials have been conducted to test whether PCI may provide any prognostic advantage over oral medical therapy (OMT) alone, without definitive results. This has maintained the paradigm of OMT as the first-line standard of care for patients, reserving PCI for symptom control. In this review, we discuss the current evidence in favour and against PCI in stable coronary syndromes and highlight the pitfalls of the available studies. We offer a critical appraisal of the possible reasons why the existing data does not provide evidence supporting the role of PCI in improving clinical outcomes in patients with stable coronary syndromes.
Collapse
Affiliation(s)
- Stefano Benenati
- Cardiovascular Disease Chair, Department of Internal Medicine (Di.M.I.), University of Genova, Genova, Italy
- Oxford Heart Centre, John Radcliffe Hospital, Oxford, UK
| | | | | | - Italo Porto
- Cardiovascular Disease Chair, Department of Internal Medicine (Di.M.I.), University of Genova, Genova, Italy
- Cardiovascular Disease Unit, IRCCS Ospedale Policlinico San Martino, IRCCS, Genova, Italy
| | | |
Collapse
|
21
|
Virani SS, Newby LK, Arnold SV, Bittner V, Brewer LC, Demeter SH, Dixon DL, Fearon WF, Hess B, Johnson HM, Kazi DS, Kolte D, Kumbhani DJ, LoFaso J, Mahtta D, Mark DB, Minissian M, Navar AM, Patel AR, Piano MR, Rodriguez F, Talbot AW, Taqueti VR, Thomas RJ, van Diepen S, Wiggins B, Williams MS. 2023 AHA/ACC/ACCP/ASPC/NLA/PCNA Guideline for the Management of Patients With Chronic Coronary Disease: A Report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines. Circulation 2023; 148:e9-e119. [PMID: 37471501 DOI: 10.1161/cir.0000000000001168] [Citation(s) in RCA: 126] [Impact Index Per Article: 126.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/22/2023]
Abstract
AIM The "2023 AHA/ACC/ACCP/ASPC/NLA/PCNA Guideline for the Management of Patients With Chronic Coronary Disease" provides an update to and consolidates new evidence since the "2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS Guideline for the Diagnosis and Management of Patients With Stable Ischemic Heart Disease" and the corresponding "2014 ACC/AHA/AATS/PCNA/SCAI/STS Focused Update of the Guideline for the Diagnosis and Management of Patients With Stable Ischemic Heart Disease." METHODS A comprehensive literature search was conducted from September 2021 to May 2022. Clinical studies, systematic reviews and meta-analyses, and other evidence conducted on human participants were identified that were published in English from MEDLINE (through PubMed), EMBASE, the Cochrane Library, Agency for Healthcare Research and Quality, and other selected databases relevant to this guideline. STRUCTURE This guideline provides an evidenced-based and patient-centered approach to management of patients with chronic coronary disease, considering social determinants of health and incorporating the principles of shared decision-making and team-based care. Relevant topics include general approaches to treatment decisions, guideline-directed management and therapy to reduce symptoms and future cardiovascular events, decision-making pertaining to revascularization in patients with chronic coronary disease, recommendations for management in special populations, patient follow-up and monitoring, evidence gaps, and areas in need of future research. Where applicable, and based on availability of cost-effectiveness data, cost-value recommendations are also provided for clinicians. Many recommendations from previously published guidelines have been updated with new evidence, and new recommendations have been created when supported by published data.
Collapse
Affiliation(s)
| | | | | | | | | | | | - Dave L Dixon
- Former Joint Committee on Clinical Practice Guideline member; current member during the writing effort
| | - William F Fearon
- Society for Cardiovascular Angiography and Interventions representative
| | | | | | | | - Dhaval Kolte
- AHA/ACC Joint Committee on Clinical Data Standards
| | | | | | | | - Daniel B Mark
- Former Joint Committee on Clinical Practice Guideline member; current member during the writing effort
| | | | | | | | - Mariann R Piano
- Former Joint Committee on Clinical Practice Guideline member; current member during the writing effort
| | | | | | | | | | | | | | | |
Collapse
|
22
|
Virani SS, Newby LK, Arnold SV, Bittner V, Brewer LC, Demeter SH, Dixon DL, Fearon WF, Hess B, Johnson HM, Kazi DS, Kolte D, Kumbhani DJ, LoFaso J, Mahtta D, Mark DB, Minissian M, Navar AM, Patel AR, Piano MR, Rodriguez F, Talbot AW, Taqueti VR, Thomas RJ, van Diepen S, Wiggins B, Williams MS. 2023 AHA/ACC/ACCP/ASPC/NLA/PCNA Guideline for the Management of Patients With Chronic Coronary Disease: A Report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines. J Am Coll Cardiol 2023; 82:833-955. [PMID: 37480922 DOI: 10.1016/j.jacc.2023.04.003] [Citation(s) in RCA: 67] [Impact Index Per Article: 67.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/24/2023]
Abstract
AIM The "2023 AHA/ACC/ACCP/ASPC/NLA/PCNA Guideline for the Management of Patients With Chronic Coronary Disease" provides an update to and consolidates new evidence since the "2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS Guideline for the Diagnosis and Management of Patients With Stable Ischemic Heart Disease" and the corresponding "2014 ACC/AHA/AATS/PCNA/SCAI/STS Focused Update of the Guideline for the Diagnosis and Management of Patients With Stable Ischemic Heart Disease." METHODS A comprehensive literature search was conducted from September 2021 to May 2022. Clinical studies, systematic reviews and meta-analyses, and other evidence conducted on human participants were identified that were published in English from MEDLINE (through PubMed), EMBASE, the Cochrane Library, Agency for Healthcare Research and Quality, and other selected databases relevant to this guideline. STRUCTURE This guideline provides an evidenced-based and patient-centered approach to management of patients with chronic coronary disease, considering social determinants of health and incorporating the principles of shared decision-making and team-based care. Relevant topics include general approaches to treatment decisions, guideline-directed management and therapy to reduce symptoms and future cardiovascular events, decision-making pertaining to revascularization in patients with chronic coronary disease, recommendations for management in special populations, patient follow-up and monitoring, evidence gaps, and areas in need of future research. Where applicable, and based on availability of cost-effectiveness data, cost-value recommendations are also provided for clinicians. Many recommendations from previously published guidelines have been updated with new evidence, and new recommendations have been created when supported by published data.
Collapse
|
23
|
Kapnisis K, Stylianou A, Kokkinidou D, Martin A, Wang D, Anderson PG, Prokopi M, Papastefanou C, Brott BC, Lemons JE, Anayiotos A. Multilevel Assessment of Stent-Induced Inflammation in the Adjacent Vascular Tissue. ACS Biomater Sci Eng 2023; 9:4747-4760. [PMID: 37480152 PMCID: PMC10428095 DOI: 10.1021/acsbiomaterials.3c00540] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Accepted: 07/12/2023] [Indexed: 07/23/2023]
Abstract
A recent U.S. Food and Drug Administration report presented the currently available scientific information related to biological response to metal implants. In this work, a multilevel approach was employed to assess the implant-induced and biocorrosion-related inflammation in the adjacent vascular tissue using a mouse stent implantation model. The implications of biocorrosion on peri-implant tissue were assessed at the macroscopic level via in vivo imaging and histomorphology. Elevated matrix metalloproteinase activity, colocalized with the site of implantation, and histological staining indicated that stent surface condition and implantation time affect the inflammatory response and subsequent formation and extent of neointima. Hematological measurements also demonstrated that accumulated metal particle contamination in blood samples from corroded-stetted mice causes a stronger immune response. At the cellular level, the stent-induced alterations in the nanostructure, cytoskeleton, and mechanical properties of circulating lymphocytes were investigated. It was found that cells from corroded-stented samples exhibited higher stiffness, in terms of Young's modulus values, compared to noncorroded and sham-stented samples. Nanomechanical modifications were also accompanied by cellular remodeling, through alterations in cell morphology and stress (F-actin) fiber characteristics. Our analysis indicates that surface wear and elevated metal particle contamination, prompted by corroded stents, may contribute to the inflammatory response and the multifactorial process of in-stent restenosis. The results also suggest that circulating lymphocytes could be a novel nanomechanical biomarker for peri-implant tissue inflammation and possibly the early stage of in-stent restenosis. Large-scale studies are warranted to further investigate these findings.
Collapse
Affiliation(s)
- Konstantinos Kapnisis
- Department
of Mechanical Engineering and Materials Science and Engineering, Cyprus University of Technology, Limassol 3036, Cyprus
| | - Andreas Stylianou
- School
of Sciences, European University Cyprus, Nicosia 2404, Cyprus
- Department
of Mechanical and Manufacturing Engineering, University of Cyprus, Nicosia 1678, Cyprus
| | - Despoina Kokkinidou
- Department
of Mechanical Engineering and Materials Science and Engineering, Cyprus University of Technology, Limassol 3036, Cyprus
| | - Adam Martin
- Department
of Pathology, University of Alabama at Birmingham, Birmingham, Alabama 35294-0111, United States
| | - Dezhi Wang
- Department
of Pathology, University of Alabama at Birmingham, Birmingham, Alabama 35294-0111, United States
| | - Peter G. Anderson
- Department
of Pathology, University of Alabama at Birmingham, Birmingham, Alabama 35294-0111, United States
| | - Marianna Prokopi
- Department
of Mechanical Engineering and Materials Science and Engineering, Cyprus University of Technology, Limassol 3036, Cyprus
| | | | - Brigitta C. Brott
- Department
of Medicine, University of Alabama at Birmingham, Birmingham, Alabama 35294-0111, United States
| | - Jack E. Lemons
- Department
of Biomedical Engineering, University of
Alabama at Birmingham, Birmingham, Alabama 35294-0111, United States
| | - Andreas Anayiotos
- Department
of Mechanical Engineering and Materials Science and Engineering, Cyprus University of Technology, Limassol 3036, Cyprus
| |
Collapse
|
24
|
Byrne RA, Fremes S, Capodanno D, Czerny M, Doenst T, Emberson JR, Falk V, Gaudino M, McMurray JJV, Mehran R, Milojevic M, Uva MS. 2022 Joint ESC/EACTS review of the 2018 guideline recommendations on the revascularization of left main coronary artery disease in patients at low surgical risk and anatomy suitable for PCI or CABG. Eur J Cardiothorac Surg 2023; 64:ezad286. [PMID: 37632766 DOI: 10.1093/ejcts/ezad286] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Revised: 06/06/2023] [Accepted: 07/15/2023] [Indexed: 08/28/2023] Open
Abstract
Task Force structure and summary of clinical evidence of 2022 ESC/EACTS review of the 2018 guideline recommendations on the revascularization of left main coronary artery disease. CABG, coronary artery bypass grafting; PCI, percutaneous coronary intervention; LM, left main; SYNTAX, Synergy Between Percutaneous Coronary Intervention with TAXUS and Cardiac Surgery. a'Event' refers to the composite of death, myocardial infarction (according to Universal Definition of Myocardial Infarction if available, otherwise protocol defined) or stroke. In October 2021, the European Society of Cardiology (ESC) and the European Association for Cardio-Thoracic Surgery (EACTS) jointly agreed to establish a Task Force (TF) to review recommendations of the 2018 ESC/EACTS Guidelines on myocardial revascularization as they apply to patients with left main (LM) disease with low-to-intermediate SYNTAX score (0-32). This followed the withdrawal of support by the EACTS in 2019 for the recommendations about the management of LM disease of the previous guideline. The TF was asked to review all new relevant data since the 2018 guidelines including updated aggregated data from the four randomized trials comparing percutaneous coronary intervention (PCI) with drug-eluting stents vs. coronary artery bypass grafting (CABG) in patients with LM disease. This document represents a summary of the work of the TF; suggested updated recommendations for the choice of revascularization modality in patients undergoing myocardial revascularization for LM disease are included. In stable patients with an indication for revascularization for LM disease, with coronary anatomy suitable for both procedures and a low predicted surgical mortality, the TF concludes that both treatment options are clinically reasonable based on patient preference, available expertise, and local operator volumes. The suggested recommendations for revascularization with CABG are Class I, Level of Evidence A. The recommendations for PCI are Class IIa, Level of Evidence A. The TF recognized several important gaps in knowledge related to revascularization in patients with LM disease and recognizes that aggregated data from the four randomized trials were still only large enough to exclude large differences in mortality.
Collapse
Affiliation(s)
- Robert A Byrne
- Department of Cardiology and Cardiovascular Research Institute (CVRI) Dublin, Mater Private Network, 73 Eccles St, Dublin D07 KWR1, Ireland
- School of Pharmacy and Biomolecular Sciences, RCSI University of Medicine and Health Sciences, 123 St Stephen's Green, Dublin D02 YN77, Ireland
| | - Stephen Fremes
- Division of Cardiac Surgery, Schulich Heart Program, Sunnybrook Health Sciences Centre, 2075 Bayview Ave, Suite H405, M4N3M5 Toronto, Canada
- Department of Surgery, University of Toronto, Toronto, Canada
| | - Davide Capodanno
- Cardio-Thoracic-Vascular and Transplant Department, Azienda Ospedaliero-Universitaria Policlinico 'Gaspare Rodolico-San Marco', University of Catania, Catania, Italy
| | - Martin Czerny
- Clinic for Cardiovascular Surgery, University Heart Center Freiburg, Bad Krozingen, Germany
- Faculty of Medicine, Albert-Ludwigs-University Freiburg, Freiburg, Germany
| | - Torsten Doenst
- Department of Cardiothoracic Surgery, University Hospital Jena, Friedrich-Schiller-University Jena, Jena, Germany
| | - Jonathan R Emberson
- Medical Research Council Population Health Research Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Volkmar Falk
- Department of Cardiothoracic and Vascular Surgery, Deutsches Herzzentrum Berlin, Berlin, Germany
- Department of Cardiovascular Surgery, Charité Universitätsmedizin Berlin, Berlin, Germany
- German Centre for Cardiovascular Research, DZHK, Partner Site Berlin, Berlin, Germany
- Department of Health Science and Technology, ETH Zurich, Zürich, Switzerland
| | - Mario Gaudino
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY, USA
| | - John J V McMurray
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow, UK
| | - Roxana Mehran
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Milan Milojevic
- Department of Cardiac Surgery and Cardiovascular Research, Dedinje Cardiovascular Institute, Belgrade, Serbia
- Department of Cardiothoracic Surgery, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Miguel Sousa Uva
- Department of Cardiac Surgery, Hospital Santa Cruz, Carnaxide, Portugal
- Department of Physiology and Cardiac Surgery, Porto University Medical School, Porto, Portugal
| |
Collapse
|
25
|
Bershtein L, Sumin A, Zbyshevskaya E, Gumerova V, Tsurtsumia D, Kochanov I, Andreeva A, Piltakian V, Sayganov S. Stable Coronary Artery Disease: Who Finally Benefits from Coronary Revascularization in the Modern Era? The ISCHEMIA and Interim ISCHEMIA-EXTEND Analysis. Life (Basel) 2023; 13:1497. [PMID: 37511870 PMCID: PMC10381336 DOI: 10.3390/life13071497] [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: 06/02/2023] [Revised: 06/26/2023] [Accepted: 06/28/2023] [Indexed: 07/30/2023] Open
Abstract
Coronary revascularization is one of the most studied treatment modalities in cardiology; however, there is no consensus among experts about its indications in patients with stable coronary artery disease (SCAD). Contemporary data regarding the role of revascularization in SCAD are in clear conflict with the current European guidelines. This article discusses the main statements of the most significant American and European Guidelines on myocardial revascularization of the last decade and also analyzes the appropriateness of revascularization to improve the prognosis and symptoms in SCAD in the light of new research data, primarily the ISCHEMIA study (NCT01471522) and the ACC/AHA 2021 Revascularization Guidelines based on them. Data on the revascularization in SCAD obtained after the completion of ISCHEMIA (including the interim analysis of ISCHEMIA-EXTEND) and their potential significance are discussed. The results of ISCHEMIA sub-analyses in the most important "controversial" subgroups (3-vessel disease, proximal left anterior descending artery disease, strongly positive stress test, etc.) are reviewed, as are the results of the ISCHEMIA-CKD substudy in patients with severe chronic kidney disease (CKD).
Collapse
Affiliation(s)
- Leonid Bershtein
- Department of Internal Medicine & Cardiology, North-Western State Medical University named after II Mechnikov, 191015 St. Petersburg, Russia
| | - Alexey Sumin
- Federal State Budgetary Institution "Research Institute for Complex Issues of Cardiovascular Disease", Sosnovy Blvd. 6, 650002 Kemerovo, Russia
| | - Elizaveta Zbyshevskaya
- Department of Internal Medicine & Cardiology, North-Western State Medical University named after II Mechnikov, 191015 St. Petersburg, Russia
| | - Victoria Gumerova
- Department of Internal Medicine & Cardiology, North-Western State Medical University named after II Mechnikov, 191015 St. Petersburg, Russia
| | - Darejan Tsurtsumia
- Department of Internal Medicine #1, North-Western State Medical University named after II Mechnikov, 191015 St. Petersburg, Russia
| | - Igor Kochanov
- Department of Interventional Cardiology, North-Western State Medical University named after II Mechnikov, 191015 St. Petersburg, Russia
| | - Alina Andreeva
- Department of Functional Diagnostics, North-Western State Medical University named after II Mechnikov, 191015 St. Petersburg, Russia
| | - Vartan Piltakian
- St. Petersburg State Budgetary Healthcare Institution 'Pokrovskaya City Hospital', 199034 St. Petersburg, Russia
| | - Sergey Sayganov
- North-Western State Medical University named after II Mechnikov, 191015 St. Petersburg, Russia
| |
Collapse
|
26
|
Campos-Varela I, Rammohan A, Chadha R, Alconchel F, Hakeem AR, Mathew JS, Goldaracena N, Syn N, Shankar S, Patel D, Keskin O, Liu J, Nasralla D, Mazzola A, Shingina A, Spiro M, Patel MS, Tanaka T, Victor D, Yoon U, Yoon YI, Shaker T, Vinaixa C, Kirchner VA, De Martin E. Proceedings of the 27th Annual Congress of the International Liver Transplantation Society. Transplantation 2023; 107:1226-1231. [PMID: 37220340 DOI: 10.1097/tp.0000000000004637] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/25/2023]
Abstract
After a virtual congress in 2021 and a previous absence in 2020 because of the coronavirus disease 2019 pandemic, the 27th Annual Congress of the International Liver Transplantation Society was held from May 4 to 7, 2022, in a hybrid format in Istanbul, with 1123 (58% on-site) liver transplant professionals from 61 countries attending the meeting. The hybrid format successfully achieved a balance of much yearned-for "in-person interaction" and global online participation. Almost 500 scientific abstracts were presented. In this report, the Vanguard Committee aims to present a summary of key invited lectures and selected abstracts for the liver transplant community.
Collapse
Affiliation(s)
- Isabel Campos-Varela
- Liver Unit, Vall d'Hebron Hospital Universitari, Vall d'Hebron Institut de Recerca (VHIR), Vall d'Hebron Barcelona Hospital Campus, Universitat Autònoma de Barcelona, Barcelona, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Instituto de Salud Carlos III, Madrid, Spain
| | - Ashwin Rammohan
- Institute of Liver Disease and Transplantation, Dr Rela Institute and Medical Centre, Bharath Institute of Higher Education and Research, Chennai, India
| | - Ryan Chadha
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Jacksonville, FL
| | | | - Abdul R Hakeem
- Department of Hepatobiliary and Liver Transplant Surgery, St James's University Hospital NHS Trust, Leeds, United Kingdom
| | | | - Nicolas Goldaracena
- Abdominal Organ Transplant and Hepatobiliary Surgery, University of Virginia Health System, Charlottesville, VA
| | | | - Sadhana Shankar
- The Liver Unit, King's College Hospital, London, United Kingdom
| | - Dhupal Patel
- Addenbrookes Hospital, Cambridge, United Kingdom
| | - Onur Keskin
- Department of Gastroenterology, Hacettepe University Medical School, Ankara, Turkey
| | - Jiang Liu
- Hepato-Pancreato-Biliary Center, Beijing Tsinghua Changgung Hospital, Tsinghua University, Beijing, China
| | - David Nasralla
- Department of HPB and Liver Transplant Surgery, The Royal Free Hospital, London, United Kingdom
| | - Alessandra Mazzola
- Sorbonne Université, Unité médicale de transplantation hépatique, AP-HP, Hôpital Pitié-Salpêtrière, Paris, France
| | - Alexandra Shingina
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Michael Spiro
- Anesthesia and Intensive Care Medicine, Royal Free Hospital, London, United Kingdom
| | | | - Tomohiro Tanaka
- Department of Internal Medicine, Gastroenterology and Hepatology, University of Iowa, Iowa City, IA
| | - David Victor
- Sherrie and Alan Conover Center for Liver Disease and Transplantation. Houston Methodist Hospital, Houston, TX
| | - Uzung Yoon
- Thomas Jefferson University Hospital, Philadelphia, PA
| | | | - Tamer Shaker
- Division of Transplantation, Department of Surgery, University of Minnesota Medical School, Minneapolis, MN
| | - Carmen Vinaixa
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Instituto de Salud Carlos III, Madrid, Spain
- Hepatology and Liver Transplantation Unit, Hospital Universitario y Politécnico La Fe, Valencia, Spain
| | - Varvara A Kirchner
- Division of Abdominal Transplantation, Department of Surgery, Stanford University, Stanford, CA
| | - Eleonora De Martin
- AP-HP, Hôpital Paul-Brousse, Centre Hépato- Biliaire, Unité INSERM 1193, Villejuif, France
| |
Collapse
|
27
|
Paolucci L, Mangiacapra F, Viscusi MM, Guarino L, Bressi E, Creta A, Di Gioia G, Capuano M, Colaiori I, Di Sciascio G, Ussia GP, Grigioni F. Impact of Endothelial Dysfunction on Long-Term Clinical Outcomes in Patients With Chronic Coronary Syndromes Treated With Second Generation Drug-Eluting Stent Implantation. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2023; 51:18-22. [PMID: 36804305 DOI: 10.1016/j.carrev.2023.02.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2022] [Revised: 01/06/2023] [Accepted: 02/02/2023] [Indexed: 02/10/2023]
Abstract
BACKGROUND Studies investigating clinical outcomes of patients with or without endothelial disfunction (ED) treated with percutaneous coronary intervention (PCI) for stable coronary artery disease (CAD) using second generation drug eluting stents (DES) are lacking. METHODS We prospectively collected data from 109 patients undergoing PCI with second generation DES due to stable CAD between December 2014 and September 2016. ED was evaluated evaluating the flow mediated dilation (FMD) at the brachial artery level and defined by an FMD < 7 %. Primary outcome were major adverse cardiovascular events (MACE), secondary outcomes were target vessel failure (TVR), myocardial infarction (MI) and all-cause death. RESULTS Five-year follow-up was available in all patients. Median FMD didn't significantly differ between patients who experienced the outcome and those who didn't [no TVR vs. TVR: p = 0.358; no MI vs. MI: p = 0.157; no death vs. death: p = 0.355; no MACE vs. MACE: p = 0.805]. No association between ED and an increased risk for the primary outcome as well as for the secondary ones was evident [MACE: 17.0 % vs. 14.3 %, HR 0.87 (0.33-2.26), log rank p = 0.780; TVR: 9.4 % vs. 5.4 %, HR 0.53 (0.12-2.24), log rank p = 0.384; MI: 3.7 % vs. 8.9 %, HR 2.46 (0.47-12.76), log rank p = 0.265; death: 7.5 % vs. 3.6 %, HR 0.53 (0.09-2.90), log rank p = 0.458]. These findings were confirmed using a lower threshold of FMD to define ED and at one-year landmark analysis. CONCLUSIONS ED is not associated with an increased risk of adverse events at long-term follow-up in a contemporary cohort of patients undergoing PCI with second generation DES.
Collapse
Affiliation(s)
- Luca Paolucci
- Unit of Cardiovascular Science, Department of Medicine, Campus Bio-Medico University, Rome, Italy.
| | - Fabio Mangiacapra
- Unit of Cardiovascular Science, Department of Medicine, Campus Bio-Medico University, Rome, Italy
| | - Michele Mattia Viscusi
- Unit of Cardiovascular Science, Department of Medicine, Campus Bio-Medico University, Rome, Italy
| | - Lorenzo Guarino
- Unit of Cardiovascular Science, Department of Medicine, Campus Bio-Medico University, Rome, Italy
| | - Edoardo Bressi
- Unit of Cardiovascular Science, Department of Medicine, Campus Bio-Medico University, Rome, Italy
| | - Antonio Creta
- Unit of Cardiovascular Science, Department of Medicine, Campus Bio-Medico University, Rome, Italy
| | - Giuseppe Di Gioia
- Unit of Cardiovascular Science, Department of Medicine, Campus Bio-Medico University, Rome, Italy; Institute of Sport Medicine and Science, National Italian Olympic Committee CONI, Rome, Italy; Department of Movement, Human and Health Sciences, University of Rome "Foro Italico", Rome, Italy
| | - Marialessia Capuano
- Unit of Cardiovascular Science, Department of Medicine, Campus Bio-Medico University, Rome, Italy
| | - Iginio Colaiori
- Unit of Cardiovascular Science, Department of Medicine, Campus Bio-Medico University, Rome, Italy
| | - Germano Di Sciascio
- Unit of Cardiovascular Science, Department of Medicine, Campus Bio-Medico University, Rome, Italy
| | - Gian Paolo Ussia
- Unit of Cardiovascular Science, Department of Medicine, Campus Bio-Medico University, Rome, Italy
| | - Francesco Grigioni
- Unit of Cardiovascular Science, Department of Medicine, Campus Bio-Medico University, Rome, Italy
| |
Collapse
|
28
|
Guo Y, Zhang W, Wu H. Percutaneous versus surgical approach to aortic valve replacement with coronary revascularization: A systematic review andmeta-analysis. Perfusion 2023:2676591231178894. [PMID: 37224394 DOI: 10.1177/02676591231178894] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Abstract
OBJECTIVE The optimal treatment of patients with severe aortic stenosis (AS) and complex coronary artery disease (CAD) remains controversial. We conducted a meta-analysis to investigate outcomes of transcatheter aortic valve replacement (TAVR) with percutaneous coronary intervention (PCI) versus surgical aortic valve replacement (SAVR) with coronary artery bypass grafting (CABG). METHODS We searched PubMed, Embase, and Cochrane databases from its inception up to 17 December 2022 for studies that assessed TAVR + PCI versus SAVR + CABG in patients with AS and CAD. The primary outcome was perioperative mortality. RESULTS Six observational studies including 135,003 patients assessing TAVI + PCI (n = 6988) versus SAVR + CABG (n = 128,015) were included. Compared to SAVR + CABG, TAVR + PCI was not significantly associated with perioperative mortality (RR, 0.76; 95% CI, 0.48-1.21; p = 0.25), vascular complications (RR, 1.85; 95% CI, 0.72-4.71; p = 0.20), acute kidney injury (RR, 0.99; 95% CI, 0.73-1.33; p = 0.95), myocardial infraction (RR, 0.73; 95% CI, 0.30-1.77; p = 0.49), or stroke (RR, 0.87; 95% CI, 0.74-1.02; p = 0.09). TAVR + PCI significantly reduced the incidence of major bleeding (RR, 0.29; 95% CI, 0.24-0.36; p < 0.01) and length of hospital stay (MD, -1.60; 95% CI, -2.45 to -0.76; p < 0.01), but increased the incidence of pacemaker implantation (RR, 2.03; 95% CI, 1.88-2.19; p < 0.01). At follow-up, TAVR + PCI was significantly associated with coronary reintervention (RR, 3.17; 95% CI, 1.03-9.71; p = 0.04) and a reduced rate of long-term survival (RR, 0.86; 95% CI, 0.79-0.94; p < 0.01). CONCLUSIONS In patients with AS and CAD, TAVR + PCI did not increase perioperative mortality, but increased the rates of coronary reintervention and long-term mortality.
Collapse
Affiliation(s)
- Yujian Guo
- Department of Graduate School, Changzhi Medical College, Changzhi, Shanxi, China
| | - Wei Zhang
- Department of Cardiothoracic Surgery, Changzhi People's Hospital, Changzhi, Shanxi, China
| | - Haibo Wu
- Department of Cardiothoracic Surgery, Changzhi People's Hospital, Changzhi, Shanxi, China
| |
Collapse
|
29
|
Kassab K, Saltiel F. Current management of coronary artery disease prior to vascular surgery: A clinical dilemma. J Perioper Pract 2023; 33:148-152. [PMID: 36285610 PMCID: PMC10160823 DOI: 10.1177/17504589221123285] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/06/2023]
Abstract
Here we present a case of an elderly man who underwent cardiac stress testing as a preoperative evaluation prior to femoral-popliteal bypass surgery. He subsequently underwent a preoperative coronary angiogram after a high-risk stress test with the latter demonstrating obstructive three-vessel coronary artery disease. We discuss the clinical challenges that such a common clinical scenario presents particularly when it comes to preoperative coronary revascularisation prior to vascular surgery. We examine the case within the framework of the latest revascularisation guidelines and discuss the available evidence for preoperative revascularisation and its limitations.
Collapse
Affiliation(s)
- Kameel Kassab
- Division of Cardiology, Borgess Heart Institute, Kalamazoo, MI, USA
- Michigan State University, East Lansing, MI, USA
| | - Frank Saltiel
- Division of Cardiology, Borgess Heart Institute, Kalamazoo, MI, USA
- Michigan State University, East Lansing, MI, USA
| |
Collapse
|
30
|
Gaudino M, Andreotti F, Kimura T. Current concepts in coronary artery revascularisation. Lancet 2023; 401:1611-1628. [PMID: 37121245 DOI: 10.1016/s0140-6736(23)00459-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2022] [Revised: 02/23/2023] [Accepted: 02/24/2023] [Indexed: 05/02/2023]
Abstract
Coronary artery revascularisation can be performed surgically or percutaneously. Surgery is associated with higher procedural risk and longer recovery than percutaneous interventions, but with long-term reduction of recurrent cardiac events. For many patients with obstructive coronary artery disease in need of revascularisation, surgical or percutaneous intervention is indicated on the basis of clinical and anatomical reasons or personal preferences. Medical therapy is a crucial accompaniment to coronary revascularisation, and data suggest that, in some subsets of patients, medical therapy alone might achieve similar results to coronary revascularisation. Most revascularisation data are based on prevalently White, non-elderly, male populations in high-income countries; robust data in women, older adults, and racial and other minorities, and from low-income and middle-income countries, are urgently needed.
Collapse
Affiliation(s)
- Mario Gaudino
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY, USA.
| | - Felicita Andreotti
- Department of Cardiovascular Sciences, Fondazione Policlinico Universitario Gemelli IRCCS, Rome, Italy
| | - Takeshi Kimura
- Department of Cardiology, Hirakata Kohsai Hospital, Osaka, Japan
| |
Collapse
|
31
|
Nardin M, Verdoia M, Laera N, Cao D, De Luca G. New Insights into Pathophysiology and New Risk Factors for ACS. J Clin Med 2023; 12:jcm12082883. [PMID: 37109221 PMCID: PMC10146393 DOI: 10.3390/jcm12082883] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Revised: 03/27/2023] [Accepted: 04/07/2023] [Indexed: 04/29/2023] Open
Abstract
Cardiovascular disease still represents the main cause of mortality worldwide. Despite huge improvements, atherosclerosis persists as the principal pathological condition, both in stable and acute presentation. Specifically, acute coronary syndromes have received substantial research and clinical attention in recent years, contributing to improve overall patients' outcome. The identification of different evolution patterns of the atherosclerotic plaque and coronary artery disease has suggested the potential need of different treatment approaches, according to the mechanisms and molecular elements involved. In addition to traditional risk factors, the finer portrayal of other metabolic and lipid-related mediators has led to higher and deep knowledge of atherosclerosis, providing potential new targets for clinical management of the patients. Finally, the impressive advances in genetics and non-coding RNAs have opened a wide field of research both on pathophysiology and the therapeutic side that are extensively under investigation.
Collapse
Affiliation(s)
- Matteo Nardin
- Department of Biomedical Sciences, Humanitas University, 20072 Milan, Italy
- Third Medicine Division, Department of Medicine, ASST Spedali Civili, 25123 Brescia, Italy
| | - Monica Verdoia
- Division of Cardiology, Ospedale degli Infermi, ASL Biella, 13900 Biella, Italy
- Department of Translational Medicine, Eastern Piedmont University, 13100 Novara, Italy
| | - Nicola Laera
- Department of Clinical and Experimental Sciences, University of Brescia, 25121 Brescia, Italy
| | - Davide Cao
- Department of Biomedical Sciences, Humanitas University, 20072 Milan, Italy
| | - Giuseppe De Luca
- Division of Cardiology, AOU "Policlinico G. Martino", Department of Clinical and Experimental Medicine, University of Messina, 98166 Messina, Italy
- Division of Cardiology, IRCCS Hospital Galeazzi-Sant'Ambrogio, 20161 Milan, Italy
| |
Collapse
|
32
|
Abstract
As society ages, the number of older adults with stable ischemic heart disease continues to rise. Older adults exhibit the greatest morbidity and mortality from stable angina. Furthermore, they suffer a higher burden of comorbidity and adverse events from treatment than younger patients. Given that older adults were excluded or underrepresented in most randomized controlled trials of stable ischemic heart disease, evidence for management is limited and hinges on subgroup analyses of trials and observational studies. This review aims to elucidate the current definitions of aging, assess the overall burden and clinical presentations of stable ischemic heart disease in older patients, weigh the available evidence for guideline-recommended treatment options including medical therapy and revascularization, and propose a framework for synthesizing complex treatment decisions in older adults with stable angina. Due to evolving goals of care in older patients, it is paramount to readdress the patient's priorities and preferences when deciding on treatment. Ultimately, the management of stable angina in older adults will need to be informed by dedicated studies in representative populations emphasizing patient-centered end points and person-centered decision-making.
Collapse
Affiliation(s)
- Michael G. Nanna
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, CT
| | - Stephen Y. Wang
- Department of Internal Medicine, Yale School of Medicine, New Haven, CT
| | - Abdulla A. Damluji
- Inova Center of Outcomes Research, Falls Church, VA
- Johns Hopkins University School of Medicine, Baltimore, MD
| |
Collapse
|
33
|
Galli M, Vescovo GM, Andreotti F, D'Amario D, Leone AM, Benenati S, Vergallo R, Niccoli G, Trani C, Porto I. Impact of coronary stenting on top of medical therapy and of inclusion of periprocedural infarctions on hard composite endpoints in patients with chronic coronary syndromes: a meta-analysis of randomized controlled trials. Minerva Cardiol Angiol 2023; 71:221-229. [PMID: 33944534 DOI: 10.23736/s2724-5683.21.05645-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
INTRODUCTION Composite endpoints are pivotal when assessing rare outcomes over relatively short follow-ups. Most randomized controlled trials (RCTs) comparing percutaneous coronary intervention (PCI) with stent implantation to optimal medical therapy (OMT) in chronic coronary syndromes (CCS) patients included both hard and soft outcomes in their primary endpoint, with periprocedural myocardial infarctions (MIs) systematically allocated to the PCI arm. We meta-analyzed the above RCTs for composite hard endpoints, with and without periprocedural MIs. EVIDENCE ACQUISITION This study is registered in PROSPERO CRD42020166754 and follows the Preferred Reporting Items for Systematic Reviews and Meta-Analyses and Cochrane Collaboration reporting. Patients had inducible ischemia, no left main disease nor severe left ventricular dysfunction. EVIDENCE SYNTHESIS Six RCTs involving 10,751 patients followed for a mean of 4.4 years were included. PCI+OMT versus OMT alone was associated with no difference in the two co-primary composite endpoints of all-cause death/MI/stroke and cardiovascular death/MI including all-MIs (IRR 0.99; 95% CI 0.90-1.08 and IRR 0.95; 95% CI 0.83-1.08 respectively). After inclusion of spontaneous rather than all-MIs (i.e., excluding periprocedural MIs), the odds showed benefit of PCI+OMT for both co-primary endpoints (IRR 0.88; 95% CI 0.80-0.97, P<0.01 and IRR 0.81; 95% CI 0.69-0.95, P=0.01 respectively) with numbers needed to treat of 42 in both cases. CONCLUSIONS Among CCS patients with inducible myocardial ischemia without severely reduced ejection fraction or left main disease, adding PCI to OMT reduces hard composite outcomes only after exclusion of periprocedural MIs. Continued efforts to define periprocedural MIs reproducibly, to assess their prognostic relevance and to prevent them are warranted.
Collapse
Affiliation(s)
- Mattia Galli
- Department of Cardiovascular and Thoracic Sciences, IRCCS A. Gemelli University Polyclinic Foundation, Rome, Italy
- Sacred Heart Catholic University, Rome, Italy
| | - Giovanni M Vescovo
- Division of Cardiology, Department of Cardiac, Thoracic and Vascular Sciences, University of Padua, Padua, Italy
| | - Felicita Andreotti
- Department of Cardiovascular and Thoracic Sciences, IRCCS A. Gemelli University Polyclinic Foundation, Rome, Italy
- Sacred Heart Catholic University, Rome, Italy
| | - Domenico D'Amario
- Department of Cardiovascular and Thoracic Sciences, IRCCS A. Gemelli University Polyclinic Foundation, Rome, Italy
| | | | - Stefano Benenati
- IRCCS San Martino University Hospital, Italian Cardiovascular Network, University of Genoa, Genoa, Italy
| | - Rocco Vergallo
- Department of Cardiovascular and Thoracic Sciences, IRCCS A. Gemelli University Polyclinic Foundation, Rome, Italy
| | - Giampaolo Niccoli
- Department of Cardiovascular and Thoracic Sciences, IRCCS A. Gemelli University Polyclinic Foundation, Rome, Italy
- Sacred Heart Catholic University, Rome, Italy
| | - Carlo Trani
- Department of Cardiovascular and Thoracic Sciences, IRCCS A. Gemelli University Polyclinic Foundation, Rome, Italy
- Sacred Heart Catholic University, Rome, Italy
| | - Italo Porto
- IRCCS San Martino University Hospital, Italian Cardiovascular Network, University of Genoa, Genoa, Italy -
- Department of Internal Medicine and Medical Specialties (DIMI), University of Genoa, Genoa, Italy
| |
Collapse
|
34
|
Seki T, Murata M, Takabayashi K, Yanagisawa T, Ogihara M, Kurimoto R, Kida K, Tamita K, Song X, Ozasa N, Taniguchi R, Nishitani-Yokoyama M, Koba S, Murai R, Furukawa Y, Hamasaki M, Kondo H, Hayashi H, Ootakara-Katsume A, Tateishi K, Matoba S, Adachi H, Shiraishi H. Cardiac Rehabilitation for Patients With Stable Ischemic Heart Disease Without Revascularization - Rationale and Design of a Single-Arm Pilot Study. Circ Rep 2023; 5:90-94. [PMID: 36909138 PMCID: PMC9992498 DOI: 10.1253/circrep.cr-22-0131] [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: 12/21/2022] [Revised: 01/12/2023] [Accepted: 01/26/2023] [Indexed: 03/12/2023] Open
Abstract
Background: Clinical practice guidelines strongly recommend optimal medical therapy (OMT), including lifestyle modification, pharmacotherapy, and exercise-based cardiac rehabilitation (CR), in patients with stable ischemic heart disease (SIHD). However, the efficacy and safety of CR in patients with SIHD without revascularization remain unclear. Methods and Results: The Prospective Registry of STable Angina RehabiliTation (Pre-START) study is a multicenter, prospective, single-arm, open-label pilot study to evaluate the efficacy and safety of CR on health-related quality of life (HRQL), exercise capacity, and clinical outcomes in Japanese patients with SIHD without revascularization. In this study, all patients will undergo guideline-based OMT and are encouraged to have 36 outpatient CR sessions within 5 months after enrollment. The primary endpoint is the change in the Seattle Angina Questionnaire-7 summary score between baseline and the 6-month visit; an improvement of ≥5 points will be defined as a clinically important change. Secondary endpoints include changes in other HRQL scores and exercise capacity between baseline and the 6-month visit, as well as clinical outcomes between enrollment and the 6-month visit. Conclusions: The Pre-START study will provide valuable evidence to elucidate the efficacy and safety of CR in patients with SIHD and indispensable information for a subsequent randomized controlled trial. The study was registered with the University Hospital Medical Information Network (UMIN) Clinical Trials Registry (ID: UMIN000045415) on April 1, 2022.
Collapse
Affiliation(s)
- Tomotsugu Seki
- Department of Cardiovascular Medicine, Graduate School of Medical Science, Kyoto Prefectural University of Medicine Kyoto Japan
| | - Makoto Murata
- Department of Cardiology, Gunma Prefectural Cardiovascular Center Maebashi Japan
| | | | - Takashi Yanagisawa
- Department of Cardiology, Saku Central Hospital Advanced Care Center Saku Japan
| | - Masayuki Ogihara
- Department of Cardiology, Saku Central Hospital Advanced Care Center Saku Japan
| | - Ritsuko Kurimoto
- Department of Cardiovascular Medicine, Graduate School of Medical Science, Kyoto Prefectural University of Medicine Kyoto Japan.,Department of Cardiology, Rakuwakai Otowa Hospital Kyoto Japan
| | - Keisuke Kida
- Department of Pharmacology, St. Marianna University School of Medicine Kawasaki Japan
| | - Koichi Tamita
- Department of Cardiology, Akashi Medical Center Akashi Japan
| | - Xiaoyang Song
- Department of Cardiovascular Medicine, Kyoto University Graduate School of Medicine Kyoto Japan
| | - Neiko Ozasa
- Department of Cardiovascular Medicine, Kyoto University Graduate School of Medicine Kyoto Japan
| | - Ryoji Taniguchi
- Department of Cardiology, Hyogo Prefectural Amagasaki General Medical Center Amagasaki Japan
| | - Miho Nishitani-Yokoyama
- Department of Cardiovascular Biology and Medicine, Juntendo University Graduate School of Medicine Tokyo Japan
| | - Shinji Koba
- Division of Cardiology, Department of Medicine, Showa University School of Medicine Tokyo Japan
| | - Ryosuke Murai
- Department of Cardiovascular Medicine, Kobe City Medical Center General Hospital Kobe Japan
| | - Yutaka Furukawa
- Department of Cardiovascular Medicine, Kobe City Medical Center General Hospital Kobe Japan
| | - Maki Hamasaki
- Department of Cardiology, Tenri Hospital Tenri Japan
| | | | | | | | | | - Satoaki Matoba
- Department of Cardiovascular Medicine, Graduate School of Medical Science, Kyoto Prefectural University of Medicine Kyoto Japan
| | - Hitoshi Adachi
- Department of Cardiology, Gunma Prefectural Cardiovascular Center Maebashi Japan
| | - Hirokazu Shiraishi
- Department of Cardiovascular Medicine, Graduate School of Medical Science, Kyoto Prefectural University of Medicine Kyoto Japan
| | | |
Collapse
|
35
|
Bakaeen FG, Chu D, Dayan V. 2021 Coronary Revascularization Guidelines-Lessons in the Importance of Data Scrutiny and Reappraisal of Evidence. JAMA Surg 2023; 158:233-234. [PMID: 36416844 DOI: 10.1001/jamasurg.2022.4796] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
This Viewpoint discusses whether or not the evidence cited in the 2021 American College of Cardiology/American Heart Association/Society for Cardiovascular Angiography &amp; Interventions guidelines for coronary artery revascularization support downgrading coronary artery bypass grafting relative to medical therapy.
Collapse
Affiliation(s)
- Faisal G Bakaeen
- Coronary Center, Department of Thoracic and Cardiovascular Surgery, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Danny Chu
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh School of Medicine, University of Pittsburgh Medical Center Heart & Vascular Surgery, Pittsburgh, Pennsylvania
| | - Victor Dayan
- Centro Cardiovascular Universitario, Montevideo, Uruguay
| |
Collapse
|
36
|
Gaba P, Gersh BJ, Muller J, Narula J, Stone GW. Evolving concepts of the vulnerable atherosclerotic plaque and the vulnerable patient: implications for patient care and future research. Nat Rev Cardiol 2023; 20:181-196. [PMID: 36151312 DOI: 10.1038/s41569-022-00769-8] [Citation(s) in RCA: 33] [Impact Index Per Article: 33.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/12/2022] [Indexed: 11/08/2022]
Abstract
Understanding the natural history of coronary artery atherosclerosis is necessary to determine prognosis and prescribe effective therapies. Traditional management of coronary artery disease has focused on the treatment of flow-limiting anatomical obstructions that lead to ischaemia. In most scenarios, revascularization of these atherosclerotic plaques has not substantially improved freedom from death or myocardial infarction, questioning the utility of contemporary revascularization strategies to improve prognosis. Advances in non-invasive and invasive imaging techniques have helped to identify the characteristics of obstructive and non-obstructive plaques that are precursors for plaque progression and future acute coronary syndromes as well as cardiac death. These 'vulnerable plaques' develop as a consequence of systemic inflammation and are prone to inducing thrombosis. Vulnerable plaques most commonly have a large plaque burden with a well-formed necrotic core and thin fibrous cap and are metabolically active. Perivascular adipose tissue might, in some patients, be used as a surrogate for coronary inflammation and predict future risk of adverse cardiac events. Vulnerable plaques can be identified in their quiescent state, offering the potential for therapeutic passivation. In this Review, we describe the biological and compositional features of vulnerable plaques, the non-invasive and invasive diagnostic modalities to characterize vulnerable plaques, the prognostic utility of identifying vulnerable plaques, and the future studies needed to explore the value of intensified pharmacological and focal treatments of vulnerable plaques.
Collapse
Affiliation(s)
- Prakriti Gaba
- Division of Cardiovascular Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Bernard J Gersh
- Department of Cardiovascular Medicine, Mayo Clinic College of Medicine and Science, Rochester, MN, USA
| | - James Muller
- Division of Cardiovascular Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Jagat Narula
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Gregg W Stone
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA.
| |
Collapse
|
37
|
Ihdayhid AR, Lan NSR, Figtree GA, Patel S, Arnott C, Hamilton-Craig C, Psaltis PJ, Leipsic J, Fairbairn T, Wahi S, Hillis GS, Rankin JM, Dwivedi G, Nicholls SJ. Contemporary Chest Pain Evaluation: The Australian Case for Cardiac CT. Heart Lung Circ 2023; 32:297-306. [PMID: 36610819 DOI: 10.1016/j.hlc.2022.12.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2022] [Revised: 10/07/2022] [Accepted: 12/06/2022] [Indexed: 01/07/2023]
Abstract
Computed tomography coronary angiography (CTCA) is a non-invasive diagnostic modality that provides a comprehensive anatomical assessment of the coronary arteries and coronary atherosclerosis, including plaque burden, composition and morphology. The past decade has witnessed an increase in the role of CTCA for evaluating patients with both stable and acute chest pain, and recent international guidelines have provided increasing support for a first line CTCA diagnostic strategy in select patients. CTCA offers some advantages over current functional tests in the detection of obstructive and non-obstructive coronary artery disease, as well as for ruling out obstructive coronary artery disease. Recent randomised trials have also shown that CTCA improves prognostication and guides the use of guideline-directed preventive therapies, leading to improved clinical outcomes. CTCA technology advances such as fractional flow reserve, plaque quantification and perivascular fat inflammation potentially allow for more personalised risk assessment and targeted therapies. Further studies evaluating demand, supply, and cost-effectiveness of CTCA for evaluating chest pain are required in Australia. This discussion paper revisits the evidence supporting the use of CTCA, provides an overview of its implications and limitations, and considers its potential role for chest pain evaluation pathways in Australia.
Collapse
Affiliation(s)
- Abdul Rahman Ihdayhid
- Department of Cardiology, Fiona Stanley Hospital, Perth, WA, Australia; Harry Perkins Institute of Medical Research, Curtin University, Perth, WA, Australia.
| | - Nick S R Lan
- Department of Cardiology, Fiona Stanley Hospital, Perth, WA, Australia; Harry Perkins Institute of Medical Research, University of Western Australia, Perth, WA, Australia
| | - Gemma A Figtree
- Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia; Kolling Institute of Medical Research, Royal North Shore Hospital, Sydney, NSW, Australia
| | - Sanjay Patel
- Department of Cardiology, Royal Prince Alfred Hospital, Sydney, NSW, Australia
| | - Clare Arnott
- Department of Cardiology, Royal Prince Alfred Hospital, Sydney, NSW, Australia; Cardiovascular Division, The George Institute for Global Health, Sydney, NSW, Australia
| | | | - Peter J Psaltis
- Department of Cardiology, Royal Adelaide Hospital, Central Adelaide Local Health Network, Adelaide, SA, Australia
| | - Jonathon Leipsic
- University of British Columbia, St Paul's Hospital, Vancouver, Canada
| | | | - Sudhir Wahi
- Princess Alexandra Hospital, University of Queensland, Brisbane, Qld, Australia
| | - Graham S Hillis
- Department of Cardiology and University of Western Australia, Royal Perth Hospital, Perth, WA, Australia
| | - James M Rankin
- Department of Cardiology, Fiona Stanley Hospital, Perth, WA, Australia
| | - Girish Dwivedi
- Department of Cardiology, Fiona Stanley Hospital, Perth, WA, Australia; Harry Perkins Institute of Medical Research, University of Western Australia, Perth, WA, Australia
| | - Stephen J Nicholls
- Monash Cardiovascular Research Centre, Victorian Heart Institute, Monash University, Melbourne, Vic, Australia
| |
Collapse
|
38
|
Kirmani B, Pullan M, Muir A. Make America Graft Again. Ann Thorac Surg 2023; 115:553. [PMID: 35351420 DOI: 10.1016/j.athoracsur.2022.03.034] [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: 01/13/2022] [Revised: 03/05/2022] [Accepted: 03/12/2022] [Indexed: 02/07/2023]
Affiliation(s)
- Bilal Kirmani
- Department of Cardiac Surgery, Liverpool Heart and Chest Hospital, Thomas Dr, Liverpool L14 3PE, United Kingdom
| | - Mark Pullan
- Department of Cardiac Surgery, Liverpool Heart and Chest Hospital, Thomas Dr, Liverpool L14 3PE, United Kingdom
| | - Andrew Muir
- Department of Cardiac Surgery, Liverpool Heart and Chest Hospital, Thomas Dr, Liverpool L14 3PE, United Kingdom.
| |
Collapse
|
39
|
Gaudino M, Di Franco A, Spadaccio C, Rahouma M, Robinson NB, Demetres M, Fremes S, Doenst T. Difference in spontaneous myocardial infarction and mortality in percutaneous versus surgical revascularization trials: A systematic review and meta-analysis. J Thorac Cardiovasc Surg 2023; 165:662-669.e14. [PMID: 34045061 PMCID: PMC8802340 DOI: 10.1016/j.jtcvs.2021.04.062] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2021] [Revised: 03/16/2021] [Accepted: 04/09/2021] [Indexed: 02/03/2023]
Abstract
OBJECTIVES It has been hypothesized that the survival benefit of coronary artery bypass (CABG) compared with percutaneous interventions (PCI) may be associated with the reduction in spontaneous myocardial infarction (SMI) achieved by surgery. This, however, has not been formally investigated. The present meta-analysis aims to evaluate the association between the difference in SMI and in survival in PCI versus CABG randomized controlled trials (RCTs). METHODS A systematic search was performed to identify all RCTs comparing PCI with CABG for the treatment of coronary artery disease and reporting SMI outcomes. Generic inverse variance method was used to pool outcomes as natural logarithms of the incident rate ratios across studies. Subgroup analysis and interaction test were used to compare the difference of the primary outcome among trials that did and did not report a significant reduction in SMI- in the patients treated by CABG. Primary outcome was all-cause mortality; secondary outcome was SMI. RESULTS Twenty RCTs were included in the meta-analysis. A statistically significant difference in SMI in favor of CABG was found in 7 of the included trials (35%). Overall, PCI was associated with significantly greater all-cause mortality (incident rate ratio, 1.13; 95% confidence interval, 1.01-1.28). At subgroup analysis, a significant difference in survival in favor of CABG was seen only in trials that reported a significant reduction in SMI in the surgical arm (P for interaction 0.02). CONCLUSIONS In the published PCI versus CABG trials, the reduction in all-cause mortality in the surgical arm is associated with the protective effect of CABG against SMI.
Collapse
Affiliation(s)
- Mario Gaudino
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY, USA
| | - Antonino Di Franco
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY, USA
| | - Cristiano Spadaccio
- Department of Cardiothoracic Surgery, Golden Jubilee National Hospital, Glasgow, United Kingdom
| | - Mohamed Rahouma
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY, USA
| | - N Bryce Robinson
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY, USA
| | - Michelle Demetres
- Samuel J. Wood Library & C.V. Starr Biomedical Information Center, Weill Cornell Medicine, New York, USA
| | - Stephen Fremes
- Schulich Heart Centre, Division of Cardiac Surgery, Department of Surgery, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Torsten Doenst
- Department of Cardiothoracic Surgery, University Hospital Jena, Friedrich Schiller University of Jena, Jena, Germany
| |
Collapse
|
40
|
Jabbour RJ, Curzen N. National Institute for Health and Care Excellence guidelines on myocardial revascularisation. Heart 2023:heartjnl-2022-321397. [PMID: 36631143 DOI: 10.1136/heartjnl-2022-321397] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Accepted: 12/09/2022] [Indexed: 01/13/2023] Open
Abstract
Cardiologists in the UK predominantly use the National Institute for Health and Care Excellence (NICE) and European Society of Cardiology guidelines to help guide decision-making. This article will appraise the current recommendations from NICE regarding myocardial revascularisation and compare them with other major international guidelines. While there are many similarities, subtle differences exist. These differences arise in part due to the evidence base at time of publication, as well as from the different healthcare systems that they are designed for, and from the cost-effectiveness models that dominate the methodology used by NICE. The clinical implications of the differences between the international guidelines will be analysed.
Collapse
Affiliation(s)
- Richard J Jabbour
- Cardiology, University Hospital Southampton NHS Foundation Trust, Southampton, UK.,Faculty of Medicine, University of Southampton, Southampton, UK
| | - Nick Curzen
- Cardiology, University Hospital Southampton NHS Foundation Trust, Southampton, UK .,Faculty of Medicine, University of Southampton, Southampton, UK
| |
Collapse
|
41
|
Hochman JS, Anthopolos R, Reynolds HR, Bangalore S, Xu Y, O’Brien SM, Mavromichalis S, Chang M, Contreras A, Rosenberg Y, Kirby R, Bhargava B, Senior R, Banfield A, Goodman SG, Lopes RD, Pracoń R, López-Sendón J, Maggioni AP, Newman JD, Berger JS, Sidhu MS, White HD, Troxel AB, Harrington RA, Boden WE, Stone GW, Mark DB, Spertus JA, Maron DJ. Survival After Invasive or Conservative Management of Stable Coronary Disease. Circulation 2023; 147:8-19. [PMID: 36335918 PMCID: PMC9797439 DOI: 10.1161/circulationaha.122.062714] [Citation(s) in RCA: 42] [Impact Index Per Article: 42.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2022] [Accepted: 10/26/2022] [Indexed: 11/09/2022]
Abstract
BACKGROUND The ISCHEMIA trial (International Study of Comparative Health Effectiveness With Medical and Invasive Approaches) compared an initial invasive versus an initial conservative management strategy for patients with chronic coronary disease and moderate or severe ischemia, with no major difference in most outcomes during a median of 3.2 years. Extended follow-up for mortality is ongoing. METHODS ISCHEMIA participants were randomized to an initial invasive strategy added to guideline-directed medical therapy or a conservative strategy. Patients with moderate or severe ischemia, ejection fraction ≥35%, and no recent acute coronary syndromes were included. Those with an unacceptable level of angina were excluded. Extended follow-up for vital status is being conducted by sites or through central death index search. Data obtained through December 2021 are included in this interim report. We analyzed all-cause, cardiovascular, and noncardiovascular mortality by randomized strategy, using nonparametric cumulative incidence estimators, Cox regression models, and Bayesian methods. Undetermined deaths were classified as cardiovascular as prespecified in the trial protocol. RESULTS Baseline characteristics for 5179 original ISCHEMIA trial participants included median age 65 years, 23% women, 16% Hispanic, 4% Black, 42% with diabetes, and median ejection fraction 0.60. A total of 557 deaths accrued during a median follow-up of 5.7 years, with 268 of these added in the extended follow-up phase. This included a total of 343 cardiovascular deaths, 192 noncardiovascular deaths, and 22 unclassified deaths. All-cause mortality was not different between randomized treatment groups (7-year rate, 12.7% in invasive strategy, 13.4% in conservative strategy; adjusted hazard ratio, 1.00 [95% CI, 0.85-1.18]). There was a lower 7-year rate cardiovascular mortality (6.4% versus 8.6%; adjusted hazard ratio, 0.78 [95% CI, 0.63-0.96]) with an initial invasive strategy but a higher 7-year rate of noncardiovascular mortality (5.6% versus 4.4%; adjusted hazard ratio, 1.44 [95% CI, 1.08-1.91]) compared with the conservative strategy. No heterogeneity of treatment effect was evident in prespecified subgroups, including multivessel coronary disease. CONCLUSIONS There was no difference in all-cause mortality with an initial invasive strategy compared with an initial conservative strategy, but there was lower risk of cardiovascular mortality and higher risk of noncardiovascular mortality with an initial invasive strategy during a median follow-up of 5.7 years. REGISTRATION URL: https://www. CLINICALTRIALS gov; Unique identifier: NCT04894877.
Collapse
Affiliation(s)
| | | | | | | | - Yifan Xu
- NYU Grossman School of Medicine, New York, NY, USA
| | | | | | | | | | | | - Ruth Kirby
- National Institutes of Health, Bethesda, MD, USA
| | | | - Roxy Senior
- Northwick Park Hospital, Harrow, London, UK
- Imperial College London and Royal Brompton Hospital, London, UK
| | | | - Shaun G. Goodman
- St. Michael’s Hospital, University of Toronto, Toronto, Ontario, Canada
| | | | - Radosław Pracoń
- Department of Coronary and Structural Heart Diseases, National Institute of Cardiology, Warsaw, Poland
| | - José López-Sendón
- IdiPaz Research Institute and Hospital Universitario La Paz, Madrid, Spain
| | | | | | | | | | - Harvey D. White
- Te Whatu Ora Health New Zealand, Te Toki Tumai, Green Lane Cardiovascular Services and University of Auckland, Auckland, NZ
| | | | | | - William E. Boden
- VA New England Healthcare System, Boston University School of Medicine, Boston, MA, USA
| | - Gregg W. Stone
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | | | - John A. Spertus
- Saint Luke’s Mid America Heart Institute and the University of Missouri, Kansas City, Kansas City, MO, USA
| | - David J. Maron
- Stanford University Department of Medicine, Stanford, CA, USA
| |
Collapse
|
42
|
Galli M, Benenati S, Zito A, Capodanno D, Zoccai GB, Ortega-Paz L, Iaconelli A, D'Amario D, Porto I, Burzotta F, Trani C, De Caterina R, Gaudino M, Escaned J, Angiolillo DJ, Crea F. Revascularization strategies versus optimal medical therapy in chronic coronary syndrome: A network meta-analysis. Int J Cardiol 2023; 370:58-64. [PMID: 36265647 DOI: 10.1016/j.ijcard.2022.10.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2022] [Revised: 10/11/2022] [Accepted: 10/12/2022] [Indexed: 11/05/2022]
Abstract
BACKGROUND The impact of myocardial revascularization on outcomes and prognosis in patients with chronic coronary syndrome (CCS) without left main (LM) disease or reduced left ventricle ejection fraction (LVEF) may be influenced by the revascularization strategy adopted. METHODS We performed a network meta-analysis including 18 randomized controlled trials comparing different revascularization strategies, including angiography-guided percutaneous coronary intervention (PCI), physiology-guided PCI and coronary artery bypass graft (CABG), in patients with CCS without LM disease or reduced LVEF. RESULTS Compared with medical therapy, all revascularization strategies were associated with a reduction of the primary endpoint, as defined in each trial, the extent of which was modest with angiography-guided PCI (IRR 0.86, 95% CI 0.75-0.99) and greater with physiology-guided PCI (IRR 0.60, 95% CI 0.47-0.77) and CABG (IRR 0.58, 95% CI 0.48-0.70). Moreover, angiography-guided PCI was associated with an increase of the primary endpoint compared to physiology-guided PCI (IRR 1.43, 95% CI 1.14-1.79) and CABG (IRR 1.49, 95% CI 1.27-1.74). CABG was the only strategy associated with reduced myocardial infarction (IRR 0.68, 95% CI 0.52-0.90), cardiovascular death (IRR 0.76, 95% CI 0.64-0.89), and all-cause death (IRR 0.87, 95% CI 0.77-0.99), but increased stroke (IRR 1.69, 95% CI 1.04-2.76). CONCLUSIONS In CCS patients without LM disease or reduced LVEF, physiology-guided PCI and CABG are associated with better outcomes than angiography-guided PCI. Compared with medical therapy, CABG is the only revascularization strategy associated with a reduction of myocardial infarction and death rates, at the cost of higher risk of stroke. STUDY REGISTRATION This study is registered in PROSPERO (CRD42022313612).
Collapse
Affiliation(s)
- Mattia Galli
- Catholic University of the Sacred Heart, Rome, Italy; Maria Cecilia Hospital, GVM Care & Research, Cotignola, Italy.
| | - Stefano Benenati
- Cardiovascular Disease Unit, IRCCS Ospedale Policlinico San Martino, IRCCS Italian Cardiology Network, Genova, Italy
| | - Andrea Zito
- Department of Cardiovascular and Thoracic Sciences, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Davide Capodanno
- Division of Cardiology, Azienda Ospedaliero Universitaria Policlinico "G. Rodolico-San Marco", University of Catania, Catania, Italy
| | - Giuseppe Biondi Zoccai
- Department of Medical-Surgical Sciences and Biotechnologies, Sapienza University, Latina, Rome, Italy; Mediterranea Cardiocentro, Napoli, Italy
| | - Luis Ortega-Paz
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, FL, United States
| | - Antonio Iaconelli
- Department of Cardiovascular and Thoracic Sciences, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Domenico D'Amario
- Department of Cardiovascular and Thoracic Sciences, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Italo Porto
- Cardiovascular Disease Unit, IRCCS Ospedale Policlinico San Martino, IRCCS Italian Cardiology Network, Genova, Italy; Cardiovascular Disease Chair, Department of Internal Medicine (Di.M.I.), University of Genoa, Genoa, Italy
| | - Francesco Burzotta
- Catholic University of the Sacred Heart, Rome, Italy; Department of Cardiovascular and Thoracic Sciences, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Carlo Trani
- Catholic University of the Sacred Heart, Rome, Italy; Department of Cardiovascular and Thoracic Sciences, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Raffaele De Caterina
- University of Pisa and University Cardiology Division, Pisa University Hospital, Pisa, Italy; Fondazione VillaSerena per la Ricerca, Città Sant'Angelo, Pescara, Italy
| | - Mario Gaudino
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York City, NY, United States
| | - Javier Escaned
- Hospital Clinico San Carlos IDISSC, Complutense University, Madrid, Spain
| | - Dominick J Angiolillo
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, FL, United States
| | - Filippo Crea
- Catholic University of the Sacred Heart, Rome, Italy; Department of Cardiovascular and Thoracic Sciences, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| |
Collapse
|
43
|
Cormican DS, Khalif A, McHugh S, Dalia AA, Drennen Z, Nuñez-Gil IJ, Ramakrishna H. Analysis of the Updated ACC/AHA Coronary Revascularization Guidelines With Implications for Cardiovascular Anesthesiologists and Intensivists. J Cardiothorac Vasc Anesth 2023; 37:135-148. [PMID: 36347728 DOI: 10.1053/j.jvca.2022.09.088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2022] [Accepted: 09/21/2022] [Indexed: 11/11/2022]
Affiliation(s)
- Daniel S Cormican
- Divisions of Cardiothoracic Anesthesiology and Critical Care Medicine, Anesthesiology Institute, Allegheny Health Network, Pittsburgh, PA
| | - Adnan Khalif
- Cardiovascular Institute, Allegheny Health Network, Pittsburgh, PA
| | - Stephen McHugh
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Adam A Dalia
- Division of Cardiac Anesthesiology, Department of Critical Care, Anesthesia, and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Zachary Drennen
- Anesthesiology Institute, Allegheny Health Network, Pittsburgh, PA
| | - Ivan J Nuñez-Gil
- Cardiovascular Institute, Hospital Clinico San Carlos, Madrid, Spain
| | - Harish Ramakrishna
- Division of Cardiovascular and Thoracic Anesthesiology, Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN.
| |
Collapse
|
44
|
Hamilton GW, Yeoh J, Dinh D, Reid CM, Yudi MB, Freeman M, Brennan A, Stub D, Oqueli E, Sebastian M, Duffy SJ, Horrigan M, Farouque O, Ajani A, Clark DJ. Trends and Real-World Safety of Patients Undergoing Percutaneous Coronary Intervention for Symptomatic Stable Ischaemic Heart Disease in Australia. Heart Lung Circ 2022; 31:1619-1629. [PMID: 36856290 DOI: 10.1016/j.hlc.2022.08.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2022] [Revised: 08/12/2022] [Accepted: 08/24/2022] [Indexed: 11/06/2022]
Abstract
BACKGROUND Percutaneous coronary intervention (PCI) in stable ischaemic heart disease (SIHD) has not been shown to improve prognosis but can alleviate symptoms and improve quality of life. Appropriately selected patients with symptoms refractory to medical therapy therefore stand to benefit, provided safety is proven. METHODS Consecutive patients undergoing PCI for SIHD between 2005-2018 in a prospective registry were included. Yearly comparisons evaluated trends, and a sub-analysis was performed comparing proximal left anterior descending artery (prox-LAD) to other-than-proximal LAD (non-pLAD) PCI. Outcomes included peri-procedural characteristics, in-hospital and 30-day event rates including MACE, and 5-year National Death Index (NDI) linked mortality. RESULTS There were 9,421 procedures included. Over time, patients were increasingly co-morbid and had higher rates of AHA/ACC class B2/C lesions, ostial stenoses, bifurcation lesions, and chronic total occlusions (all p-for-trend ≤0.001). Over 14 years, major bleeding reduced (1.05% in 2005/06 vs 0.29% in 2017/18, p-for-trend <0.001), while other in-hospital and 30-day event rates were stably low. There were only seven (0.07%) in hospital deaths and 5-year mortality was 10.3%. No differences were found in outcomes between patients who underwent prox-LAD compared to non-pLAD PCI. Major independent predictors of NDI linked all-cause mortality included an eGFR <30 mL/min/1.73 m2 (HR 4.06, 95% CI 3.26-5.06), chronic obstructive pulmonary disease (COPD) (HR 2.25, 95% CI 1.89-2.67) and LVEF <30% (HR 2.13, 95% CI 1.57-2.89). CONCLUSIONS Although patient and procedural complexity increased over time, a high degree of procedural success and safety was maintained, including in those undergoing prox-LAD PCI. These real-world data can enhance shared decision making discussions regarding whether PCI should be pursued in patients with symptomatic SIHD refractory to medical therapy.
Collapse
Affiliation(s)
- Garry W Hamilton
- Department of Cardiology, Austin Health, Melbourne, Vic, Australia; Department of Medicine, University of Melbourne, Melbourne, Vic, Australia
| | - Julian Yeoh
- Department of Cardiology, Austin Health, Melbourne, Vic, Australia
| | - Diem Dinh
- Centre of Cardiovascular Research and Education in Therapeutics (CCRET), Monash University, Melbourne, Vic, Australia
| | - Christopher M Reid
- Centre of Cardiovascular Research and Education in Therapeutics (CCRET), Monash University, Melbourne, Vic, Australia; School of Public Health, Curtin University, Perth, WA, Australia
| | - Matias B Yudi
- Department of Cardiology, Austin Health, Melbourne, Vic, Australia; Department of Medicine, University of Melbourne, Melbourne, Vic, Australia
| | - Melanie Freeman
- Department of Cardiology, Box Hill Hospital, Melbourne, Vic, Australia
| | - Angela Brennan
- Centre of Cardiovascular Research and Education in Therapeutics (CCRET), Monash University, Melbourne, Vic, Australia
| | - Dion Stub
- Centre of Cardiovascular Research and Education in Therapeutics (CCRET), Monash University, Melbourne, Vic, Australia; Department of Cardiovascular Medicine, Alfred Hospital, Melbourne, Vic, Australia
| | - Ernesto Oqueli
- Department of Cardiology, Ballarat Base Hospital, Ballarat, Vic, Australia
| | - Martin Sebastian
- Department of Cardiology, University Hospital Geelong, Vic, Australia
| | - Stephen J Duffy
- Centre of Cardiovascular Research and Education in Therapeutics (CCRET), Monash University, Melbourne, Vic, Australia; Department of Cardiovascular Medicine, Alfred Hospital, Melbourne, Vic, Australia
| | - Mark Horrigan
- Department of Cardiology, Austin Health, Melbourne, Vic, Australia
| | - Omar Farouque
- Department of Cardiology, Austin Health, Melbourne, Vic, Australia; Department of Medicine, University of Melbourne, Melbourne, Vic, Australia
| | - Andrew Ajani
- Centre of Cardiovascular Research and Education in Therapeutics (CCRET), Monash University, Melbourne, Vic, Australia; Department of Cardiology, Royal Melbourne Hospital, Melbourne, Vic, Australia
| | - David J Clark
- Department of Cardiology, Austin Health, Melbourne, Vic, Australia; Centre of Cardiovascular Research and Education in Therapeutics (CCRET), Monash University, Melbourne, Vic, Australia.
| |
Collapse
|
45
|
Armstrong PW, Bates ER, Gaudino M. Left main coronary disease: evolving management concepts. Eur Heart J 2022; 43:4635-4643. [PMID: 36173870 DOI: 10.1093/eurheartj/ehac542] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Revised: 07/25/2022] [Accepted: 09/16/2022] [Indexed: 01/05/2023] Open
Abstract
Remarkable advances in the management of coronary artery disease have enhanced our approach to left main coronary artery (LMCA) disease. The traditional role of coronary artery bypass graft surgery has been challenged by the less invasive percutaneous coronary interventional approach. Additionally, major strides in optimal medical therapy now provide a rich menu of treatment choices in selected circumstances. Although a LMCA stenosis >70% is an acceptable threshold for revascularization, those patients with a LMCA narrowing between 40 and 69% present a more complex scenario. This review examines the relative merits of the different treatment options, addresses key diagnostic and therapeutic unknowns, and identifies future work likely to advance progress.
Collapse
Affiliation(s)
- Paul W Armstrong
- Canadian VIGOUR Centre, University of Alberta, 4-120 Katz Group Centre for Pharmacy and Health Research, Edmonton, AB T6G 2E1, Canada.,Division of Cardiology, Department of Medicine, University of Alberta, 2C2 Cardiology Walter MacKenzie Center, University of Alberta Hospital, 8440-111 St., Edmonton, AB T6G 2B7, Canada
| | - Eric R Bates
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Michigan, 1500 E. Medical Center Drive 2139 Cardiovascular Center, Ann Arbor, MI 48109, USA
| | - Mario Gaudino
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, 525 East 68th St, Box 110, New York, NY 10065, USA
| |
Collapse
|
46
|
Shiono Y. Benefits of Fractional Flow Reserve-Guided Percutaneous Coronary Intervention. JACC. ASIA 2022; 2:604-606. [PMID: 36624787 PMCID: PMC9823274 DOI: 10.1016/j.jacasi.2022.05.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Affiliation(s)
- Yasutsugu Shiono
- Address for correspondence: Dr Yasutsugu Shiono, Department of Cardiovascular Medicine, Wakayama Medical University, 811-1, Kimiidera, Wakayama 641-8509, Japan.
| |
Collapse
|
47
|
Doenst T, Thiele H, Haasenritter J, Wahlers T, Massberg S, Haverich A. The Treatment of Coronary Artery Disease. DEUTSCHES ARZTEBLATT INTERNATIONAL 2022; 119:716-723. [PMID: 35912444 PMCID: PMC9835700 DOI: 10.3238/arztebl.m2022.0277] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/06/2022] [Revised: 04/06/2022] [Accepted: 07/06/2022] [Indexed: 11/05/2022]
Abstract
BACKGROUND The first coronary artery bypass operation (CABG) was performed on May 2, 1960. The first percutaneous coro - nary intervention (PCI) was performed almost 20 years later. Since then, the invasive treatment of coronary artery disease (CAD) has moved into the spotlight of cardiac medical care. METHODS We summarize the current status of medical and invasive CAD treatment through a selective review of the literature. RESULTS More than 800 000 patients currently undergo invasive diagnostic and therapeutic procedures for CAD in Germany each year. The number of coronary artery bypass grafting (CABG) procedures rose to 65 000/year by the turn of the millennium and has been declining since then. In contrast, the number of PCIs in Germany rose to approximately 350 000/year by 2017, and a beginning decline is being observed at present. This development occurred even though, for elective patients, a survival advantage from an invasive procedure compared to medical therapy has been shown in direct comparison only for CABG. CONCLUSION Conservative treatment is always the baseline treatment and has undergone major advances in the last few decades. Moreover, non-invasive coronary evaluation with computed tomography, as well as non-invasive cardiac stress imaging studies, are increasingly replacing primary invasive coronary evaluations. In this review, we illustrate a mechanistic concept of the appropriate use of CABG and PCI that can improve patient care, while underscoring the importance of interdisciplinary and intersectoral collaboration.
Collapse
Affiliation(s)
- Torsten Doenst
- Department of Cardiothoracic Surgery at Jena University Hospital, Friedrich-Schiller University of Jena,*Department of Cardiothoracic Surgery at Jena University Hospital Am Klinikum 1, 07747 Jena
| | - Holger Thiele
- University Department of Cardiology, Leipzig Heart Center
| | - Jörg Haasenritter
- Department of General Practice, Preventive and Rehabilitation Medicine, Philipps University of Marburg
| | - Thorsten Wahlers
- Department of Heart Surgery, Intensive Care Medicine and Thoracic Surgery at University Hospital of Cologne
| | - Steffen Massberg
- Medical Clinic and Polyclinic I, University Hospital of Ludwig Maximilian University of Munich,German Center for Cardiovascular Research (DZHK)
| | - Axel Haverich
- Department of Cardiothoracic, Transplantation and Vascular Surgery, Hanover Medical School
| |
Collapse
|
48
|
Clinical outcomes and echocardiographic characteristics between African American and Caucasian patients with acute pulmonary embolism. Phlebology 2022; 37:678-685. [DOI: 10.1177/02683555221128120] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background Despite socioeconomic disparities, no association between clinical presentation and poor outcomes explains a higher mortality in African Americans with pulmonary embolism (PE). The objective is to identify the co-morbidities and echocardiographic characteristics associated with increased mortality in African American patients. Methods This is a cross-sectional study of Caucasian or African American patients with PE diagnosed between October 2015 and December 2017 at University of Maryland Medical Center. The outcomes were in-hospital death, length of stay, and bleeding. Results There were 303 African Americans and 343 Caucasians. Caucasians were older ( p = 0.007), males ( p = 0.01) with history of coronary artery revascularization (CABG ( p = 0.001), coronary stents ( p = 0.001)), trauma ( p = 0.007), and/or recent surgeries ( p = 0.0001). African Americans exhibited higher rates of diabetes ( p = 0.01), chronic kidney disease ( p = 0.0005), and smoking ( p = 0.04). Severity of PE was similar between groups and there was no difference in clot burden size. African Americans had more right ventricular strain on Computer Tomography ( p = 0.001) and echocardiogram ( p = 0.004); also, underfilled left ventricles ( p = 0.02) and higher right ventricular systolic pressures ( p = 0.001). There was no difference in hospital mortality (7.1% vs. 7.9%, p = 0.71), length of stay (13.1 ± 16.7 vs 12.8 ± 14.9, p = 0.80) and bleeding (9.0% vs.8.3%. p = 0.72). Mortality was higher in African Americans who received advanced therapies (3.8% vs. 18.8%, p = 0.02). The risk of death increased with age (OR 1.04; 95%CI 1.020–1.073) and with advanced therapies (OR 2.43; 95%CI 1.029–5.769). Conclusions Differences in co-morbidities, radiologic findings, and echocardiographic characteristics that may contribute to higher mortality in African American patients, specifically those receiving advanced therapies.
Collapse
|
49
|
Spirito A, Cao D, Mehran R. Subjective angina or myocardial ischaemia to justify PCI? Never mistake the finger for the moon. Eur Heart J 2022; 43:3145-3147. [PMID: 35789263 DOI: 10.1093/eurheartj/ehac353] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Affiliation(s)
- Alessandro Spirito
- Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
| | - Davide Cao
- Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA.,Cardio Center, Humanitas Research Hospital IRCCS, Milan, Italy
| | - Roxana Mehran
- Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
| |
Collapse
|
50
|
Bittl JA, Tamis-Holland JE, Lawton JS. Does Bypass Surgery or Percutaneous Coronary Intervention Improve Survival in Stable Ischemic Heart Disease? JACC Cardiovasc Interv 2022; 15:1243-1248. [PMID: 35583361 DOI: 10.1016/j.jcin.2022.05.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2022] [Accepted: 05/05/2022] [Indexed: 11/18/2022]
Affiliation(s)
- John A Bittl
- Scientific Publishing Committee, American College of Cardiology, Washington, DC, USA.
| | | | - Jennifer S Lawton
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| |
Collapse
|