1
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Warisawa T, Cook CM, Ahmad Y, Howard JP, Seligman H, Rajkumar C, Toya T, Doi S, Nakajima A, Nakayama M, Vera-Urquiza R, Yuasa S, Sato T, Kikuta Y, Kawase Y, Nishina H, Al-Lamee R, Sen S, Lerman A, Matsuo H, Akashi YJ, Escaned J, Davies JE. Deferred Versus Performed Revascularization for Left Main Coronary Disease With Hemodynamic Significance. Circ Cardiovasc Interv 2023; 16:e012700. [PMID: 37339234 DOI: 10.1161/circinterventions.122.012700] [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: 10/30/2022] [Accepted: 03/24/2023] [Indexed: 06/22/2023]
Abstract
BACKGROUND The majority of randomized controlled trials of revascularization decision-making excludes left main coronary artery disease (LMD). Therefore, contemporary clinical outcomes of patients with stable coronary artery disease and LMD with proven ischemia remain poorly understood. The aim of this study was to assess the long-term clinical outcomes of physiologically significant LMD according to the treatment strategies of revascularization versus revascularization deferral. METHODS In this international multicenter registry of stable LMD interrogated with the instantaneous wave-free ratio, patients with physiologically significant ischemia (instantaneous wave-free ratio ≤0.89) were analyzed according to the coronary revascularization (n=151) versus revascularization deferral (n=74). Propensity score matching was performed to adjust for baseline clinical characteristics. The primary end point was a composite of death, nonfatal myocardial infarction, and ischemia-driven target lesion revascularization of left main stem. The secondary end points were as follows: cardiac death or spontaneous LMD-related myocardial infarction; and ischemia-driven target lesion revascularization of left main stem. RESULTS At a median follow-up period of 2.8 years, the primary end point occurred in 11 patients (14.9%) in the revascularized group and 21 patients (28.4%) in the deferred group (hazard ratio, 0.42 [95% CI, 0.20-0.89]; P=0.023). For the secondary end points, cardiac death or LMD-related myocardial infarction occurred significantly less frequently in the revascularized group (0.0% versus 8.1%; P=0.004). The rate of ischemia-driven target lesion revascularization of left main stem was also significantly lower in the revascularized group (5.4% versus 17.6%; hazard ratio, 0.20 [95% CI, 0.056-0.70]; P=0.012). CONCLUSIONS In patients who underwent revascularization for stable coronary artery disease and physiologically significant LMD determined by instantaneous wave-free ratio, the long-term clinical outcomes were significantly improved as compared with those in whom revascularization was deferred.
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Affiliation(s)
- Takayuki Warisawa
- Division of Cardiology, Department of Internal Medicine, St Marianna University School of Medicine, Kawasaki, Japan (T.W., S.D., Y.J.A.)
- Department of Cardiology, NTT Medical Center Tokyo, Japan (T.W.)
- National Heart and Lung Institute, Imperial College London, UK (T.W., J.P.H., H.S., C.R., Y.K., R.A.-L., S.S., J.E.D.)
| | - Christopher M Cook
- The Essex Cardiothroacic Centre, UK (C.M.K.)
- Anglia Ruskin University, Essex, UK (C.M.K.)
| | - Yousif Ahmad
- Cardiovascular Medicine, Yale School of Medicine, New Haven, CT (Y.A.)
| | - James P Howard
- National Heart and Lung Institute, Imperial College London, UK (T.W., J.P.H., H.S., C.R., Y.K., R.A.-L., S.S., J.E.D.)
- Cardiovascular Science, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, UK (J.P.H., H.S., C.R., R.A.-L., S.S.)
| | - Henry Seligman
- National Heart and Lung Institute, Imperial College London, UK (T.W., J.P.H., H.S., C.R., Y.K., R.A.-L., S.S., J.E.D.)
- Cardiovascular Science, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, UK (J.P.H., H.S., C.R., R.A.-L., S.S.)
| | - Christopher Rajkumar
- National Heart and Lung Institute, Imperial College London, UK (T.W., J.P.H., H.S., C.R., Y.K., R.A.-L., S.S., J.E.D.)
- Cardiovascular Science, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, UK (J.P.H., H.S., C.R., R.A.-L., S.S.)
| | - Takumi Toya
- Department of Cardiology, National Defense Medical College, Tokorozawa, Japan (T.T.)
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN (T.T., A.L.)
| | - Shunichi Doi
- Division of Cardiology, Department of Internal Medicine, St Marianna University School of Medicine, Kawasaki, Japan (T.W., S.D., Y.J.A.)
| | - Akihiro Nakajima
- Department of Cardiovascular Medicine, New Tokyo Hospital, Matsudo, Japan (A.N.)
| | - Masafumi Nakayama
- Department of Cardiovascular Medicine, Gifu Heart Center, Japan (M.N., Y.K., H.M.)
- Cardiovascular Center, Toda Central General Hospital, Japan (M.N.)
| | - Rafael Vera-Urquiza
- Hospital Clinico San Carlos IDISSC, Complutense University of Madrid, Spain (R.V.-U., S.Y., J.E.)
| | - Sonoka Yuasa
- Hospital Clinico San Carlos IDISSC, Complutense University of Madrid, Spain (R.V.-U., S.Y., J.E.)
| | - Takao Sato
- Department of Cardiology, Tachikawa General Hospital, Nagaoka, Japan (T.S.)
| | - Yuetsu Kikuta
- National Heart and Lung Institute, Imperial College London, UK (T.W., J.P.H., H.S., C.R., Y.K., R.A.-L., S.S., J.E.D.)
- Department of Cardiovascular Medicine, Gifu Heart Center, Japan (M.N., Y.K., H.M.)
- Division of Cardiology, Fukuyama Cardiovascular Hospital, Japan (Y.K.)
| | | | - Hidetaka Nishina
- Department of Cardiology, Tsukuba Medical Center Hospital, Japan (H.N.)
| | - Rasha Al-Lamee
- National Heart and Lung Institute, Imperial College London, UK (T.W., J.P.H., H.S., C.R., Y.K., R.A.-L., S.S., J.E.D.)
- Cardiovascular Science, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, UK (J.P.H., H.S., C.R., R.A.-L., S.S.)
| | - Sayan Sen
- National Heart and Lung Institute, Imperial College London, UK (T.W., J.P.H., H.S., C.R., Y.K., R.A.-L., S.S., J.E.D.)
- Cardiovascular Science, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, UK (J.P.H., H.S., C.R., R.A.-L., S.S.)
| | - Amir Lerman
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN (T.T., A.L.)
| | - Hitoshi Matsuo
- Department of Cardiovascular Medicine, Gifu Heart Center, Japan (M.N., Y.K., H.M.)
| | - Yoshihiro J Akashi
- Division of Cardiology, Department of Internal Medicine, St Marianna University School of Medicine, Kawasaki, Japan (T.W., S.D., Y.J.A.)
| | - Javier Escaned
- Hospital Clinico San Carlos IDISSC, Complutense University of Madrid, Spain (R.V.-U., S.Y., J.E.)
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2
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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: 40] [Impact Index Per Article: 40.0] [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.
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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.
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3
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Kattih B, Operhalski F, Boeckling F, Hecker F, Michael F, Vamos M, Hohnloser SH, Erath JW. Clinical outcomes of subcutaneous vs. transvenous implantable defibrillator therapy in a polymorbid patient cohort. Front Cardiovasc Med 2022; 9:1008311. [PMID: 36330004 PMCID: PMC9624387 DOI: 10.3389/fcvm.2022.1008311] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2022] [Accepted: 10/05/2022] [Indexed: 11/13/2022] Open
Abstract
Background The subcutaneous implantable cardioverter-defibrillator (S-ICD) has been designed to overcome lead-related complications and device endocarditis. Lacking the ability for pacing or resynchronization therapy its usage is limited to selected patients at risk for sudden cardiac death (SCD). Objective The aim of this single-center study was to assess clinical outcomes of S-ICD and single-chamber transvenous (TV)-ICD in an all-comers population. Methods The study cohort comprised a total of 119 ICD patients who underwent either S-ICD (n = 35) or TV-ICD (n = 84) implantation at the University Hospital Frankfurt from 2009 to 2017. By applying an inverse probability-weighting (IPW) analysis based on the propensity score including the Charlson Comorbidity Index (CCI) to adjust for potential extracardiac comorbidities, we aimed for head-to-head comparison on the study composite endpoint: overall survival, hospitalization, and device-associated events (including appropriate and inappropriate shocks or system-related complications). Results The median age of the study population was 66.0 years, 22.7% of the patients were female. The underlying heart disease was ischemic cardiomyopathy (61.4%) with a median LVEF of 30%. Only 52.9% had received an ICD for primary prevention, most of the patients (67.3%) had advanced heart failure (NYHA class II–III) and 16.8% were in atrial fibrillation. CCI was 5 points in TV-ICD patients vs. 4 points for patients with S-ICD (p = 0.209) indicating increased morbidity. The composite endpoint occurred in 38 patients (31.9 %), revealing no significant difference between patients implanted with an S-ICD or TV-ICD (unweighted HR 1.50, 95 % confidence interval (CI) 0.78–2.90; p = 0.229, weighted HR 0.94, 95% CI, 0.61–1.50, p = 0.777). Furthermore, we observed no difference in any single clinical endpoint or device-associated outcome, neither in the unweighted cohort nor following inverse probability-weighting. Conclusion Clinical outcomes of the S-ICD and TV-ICD revealed no differences in the composite endpoint including survival, freedom of hospitalization and device-associated events, even after careful adjustment for potential confounders. Moreover, the CCI was evaluated in a S-ICD cohort demonstrating higher survival rates than predicted by the CCI in young, polymorbid (S-)ICD patients.
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Affiliation(s)
- Badder Kattih
- Division of Clinical Electrophysiology, Department of Cardiology, University Hospital Frankfurt, J. W. Goethe University, Frankfurt am Main, Germany
| | - Felix Operhalski
- Division of Clinical Electrophysiology, Department of Cardiology, University Hospital Frankfurt, J. W. Goethe University, Frankfurt am Main, Germany
| | - Felicitas Boeckling
- Division of Clinical Electrophysiology, Department of Cardiology, University Hospital Frankfurt, J. W. Goethe University, Frankfurt am Main, Germany
| | - Florian Hecker
- Department of Cardiac Surgery, University Hospital Frankfurt, J. W. Goethe University, Frankfurt am Main, Germany
| | - Felix Michael
- Division of Clinical Electrophysiology, Department of Cardiology, University Hospital Frankfurt, J. W. Goethe University, Frankfurt am Main, Germany
| | - Mate Vamos
- Cardiac Electrophysiology Division, Department of Internal Medicine, University of Szeged, Szeged, Hungary
| | - Stefan H. Hohnloser
- Division of Clinical Electrophysiology, Department of Cardiology, University Hospital Frankfurt, J. W. Goethe University, Frankfurt am Main, Germany
| | - Julia W. Erath
- Division of Clinical Electrophysiology, Department of Cardiology, University Hospital Frankfurt, J. W. Goethe University, Frankfurt am Main, Germany
- *Correspondence: Julia W. Erath
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4
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Halvorsen S, Mehilli J, Cassese S, Hall TS, Abdelhamid M, Barbato E, De Hert S, de Laval I, Geisler T, Hinterbuchner L, Ibanez B, Lenarczyk R, Mansmann UR, McGreavy P, Mueller C, Muneretto C, Niessner A, Potpara TS, Ristić A, Sade LE, Schirmer H, Schüpke S, Sillesen H, Skulstad H, Torracca L, Tutarel O, Van Der Meer P, Wojakowski W, Zacharowski K. 2022 ESC Guidelines on cardiovascular assessment and management of patients undergoing non-cardiac surgery. Eur Heart J 2022; 43:3826-3924. [PMID: 36017553 DOI: 10.1093/eurheartj/ehac270] [Citation(s) in RCA: 284] [Impact Index Per Article: 142.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
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5
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Evaluation and management of chronic kidney disease patients with stable ischemic heart disease. Atherosclerosis 2022; 351:26-28. [DOI: 10.1016/j.atherosclerosis.2022.05.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2022] [Revised: 05/05/2022] [Accepted: 05/10/2022] [Indexed: 11/19/2022]
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6
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Nakano S, Kohsaka S, Chikamori T, Fukushima K, Kobayashi Y, Kozuma K, Manabe S, Matsuo H, Nakamura M, Ohno T, Sawano M, Toda K, Ueda Y, Yokoi H, Gatate Y, Kasai T, Kawase Y, Matsumoto N, Mori H, Nakazato R, Niimi N, Saito Y, Shintani A, Watanabe I, Watanabe Y, Ikari Y, Jinzaki M, Kosuge M, Nakajima K, Kimura T. JCS 2022 Guideline Focused Update on Diagnosis and Treatment in Patients With Stable Coronary Artery Disease. Circ J 2022; 86:882-915. [DOI: 10.1253/circj.cj-21-1041] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Affiliation(s)
- Shintaro Nakano
- Cardiology, Saitama Medical University International Medical Center
| | | | | | - Kenji Fukushima
- Department of Radiology and Nuclear Medicine, Fukushima Medical University
| | | | - Ken Kozuma
- Cardiology, Teikyo University School of Medicine
| | - Susumu Manabe
- Cardiac Surgery, International University of Health and Welfare Mita Hospital
| | | | - Masato Nakamura
- Cardiovascular Medicine, Toho University Ohashi Medical Center
| | | | | | - Koichi Toda
- Cardiovascular Surgery, Osaka University Graduate School of Medicine
| | - Yasunori Ueda
- Cardiovascular Division, National Hospital Organization Osaka National Hospital
| | - Hiroyoshi Yokoi
- Cardiovascular Center, International University of Health and Welfare Fukuoka Sanno Hospital
| | - Yodo Gatate
- Cardiology, Self-Defense Forces Central Hospital
| | | | | | | | - Hitoshi Mori
- Cardiology, Saitama Medical University International Medical Center
| | | | | | - Yuichi Saito
- Cardiovascular Medicine, Chiba University School of Medicine
| | - Ayumi Shintani
- Medical Statistics, Osaka City University Graduate School of Medicine
| | - Ippei Watanabe
- Cardiovascular Medicine, Toho University School of Medicine
| | | | - Yuji Ikari
- Cardiology, Tokai University School of Medicine
| | | | | | - Kenichi Nakajima
- Functional Imaging and Artificial Intelligence, Kanazawa University
| | - Takeshi Kimura
- Cardiovascular Medicine, Kyoto University Graduate School of Medicine
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7
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Butman SM. This is the best generation, for now. Catheter Cardiovasc Interv 2021; 98:468-469. [PMID: 34498400 DOI: 10.1002/ccd.29882] [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: 07/05/2021] [Accepted: 07/10/2021] [Indexed: 11/06/2022]
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8
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Lehrke M, Niemann B. [Coronary revascularization: Interventional therapy or coronary bypass surgery]. Dtsch Med Wochenschr 2021; 146:1051-1058. [PMID: 34416772 DOI: 10.1055/a-1241-6645] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Coronary artery disease remains the leading cause of death and is responsible for myocardial infarction, heart failure and angina. Therapy combines optimal control of cardiovascular risk factors with coronary revascularization performed by interventional therapy or bypass surgery. While interventional therapy is preferred for single or two vessel disease, interdisciplinary heart team decision should be reached for complex lesion, three vessel or left main disease. Both revascularization strategies perform similar for low level complexity three vessel or left main disease while coronary bypass surgery proved superior for more complex coronary artery disease. Heart team decision should be based on vascular anatomy and expected revascularization success under consideration of operative risk and patient preference.
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9
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Suzuki K, Claggett B, Minamisawa M, Packer M, Zile MR, Pfeffer MA, Chiang LM, Lefkowitz M, McMurray JJV, Solomon SD, Desai AS. Influence of study discontinuation during the run-in period on the estimated efficacy of sacubitril/valsartan in the PARAGON-HF trial. Eur J Heart Fail 2021; 23:2085-2090. [PMID: 34114720 DOI: 10.1002/ejhf.2262] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2020] [Revised: 05/28/2021] [Accepted: 06/05/2021] [Indexed: 11/11/2022] Open
Abstract
AIMS The 4822 patients randomized in the PARAGON-HF trial were a subset of 5746 initially eligible patients who entered sequential run-in periods. We identified patient factors associated with study discontinuation during the run-in period and estimated the implications of these discontinuations for the overall study result. METHODS AND RESULTS We utilized multivariable logistic regression models to identify patient factors associated with study discontinuation during the run-in period. The efficacy of sacubitril/valsartan in a broader cohort approximating the full run-in population was estimated by weighting randomized patients according to the inverse probability of run-in completion. A total of 924 (16.1%) subjects failed to complete the run-in period. In multivariable models, non-completion was associated with region other than Central Europe, lower systolic blood pressure, lower serum sodium, lower haemoglobin, lower estimated glomerular filtration rate, higher N-terminal pro-B-type natriuretic peptide, higher New York Heart Association functional class, prior heart failure (HF) hospitalization, and lack of prior use of renin-angiotensin system inhibitors or beta-blocker. In repeat analysis of the effect of randomized treatment in PARAGON-HF giving greater weight to participants resembling those who failed to complete the run-in period, the incidence of HF hospitalizations and cardiovascular death was higher, and sacubitril/valsartan treatment reduced the composite of total HF hospitalizations and cardiovascular death compared with valsartan (rate ratio 0.86; 95% confidence interval 0.74-1.00). CONCLUSION Patients with more advanced HF were at higher risk for non-completion of the run-in period in PARAGON-HF. Re-analysis of study outcomes accounting for the effect of run-in non-completion did not alter the estimated treatment effects of sacubitril/valsartan vs. valsartan.
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Affiliation(s)
- Kota Suzuki
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Brian Claggett
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Masatoshi Minamisawa
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Milton Packer
- Baylor Heart and Vascular Institute, Baylor University Medical Center, Dallas, TX, USA
| | - Michael R Zile
- Ralph H. Johnson Department of Veterans Affairs Medical Center, Charleston, SC, USA
| | - Marc A Pfeffer
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | | | | | - John J V McMurray
- BHF Cardiovascular Research Centre, University of Glasgow, Glasgow, UK
| | - Scott D Solomon
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Akshay S Desai
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA, USA
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10
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King SB. What to Do About Stable Ischemic Heart Disease? - The Age Old Question. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2021; 26:71-72. [PMID: 33744104 DOI: 10.1016/j.carrev.2021.02.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2021] [Accepted: 02/05/2021] [Indexed: 10/21/2022]
Affiliation(s)
- Spencer B King
- 5665 Peachtree Dunwoody Road NE, Atlanta, GA 30342, United States of America.
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11
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Schmermund A, Breitbart P, Eckert J, Magedanz A, Schmidt M, Voigtländer T. 2020: Entwicklungen in der kardialen Computertomographie. DER KARDIOLOGE 2021. [PMCID: PMC7921831 DOI: 10.1007/s12181-021-00454-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/04/2022]
Abstract
Die Entwicklung der kardialen Computertomographie (CT) im Jahr 2020 war durch 3 dominante Schwerpunkte im Bereich der koronaren Bildgebung gekennzeichnet: 1) die prognostische Bedeutung der Plaquebildung, 2) die Möglichkeit ihrer volumetrischen Quantifizierung und 3) den Bedeutungsgewinn in den Leitlinien, verstärkt durch die zunehmende Anwendung in der Therapie von strukturellen Herzerkrankungen. Die Veröffentlichung der Ergebnisse von ISCHEMIA (International Study of Comparative Health Effectiveness with Medical and Invasive Approaches) hat den Blick auf die anatomische Charakterisierung der koronaren Herzkrankheit gelenkt, die Visualisierung der koronaren Plaquebildung. Nicht zuletzt als Ergebnis von „machine learning“/künstlicher Intelligenz hat sich die Möglichkeit herauskristallisiert, die koronare Plaquebildung automatisiert und volumetrisch zu erfassen. Diese beiden Entwicklungen haben die Frage nach der prognostischen Dominanz des Ischämienachweises aufgeworfen, der sekundär aus der Plaquebildung resultiert. Auch hat sich das Verständnis der Pathophysiologie der koronaren Herzerkrankung verändert: Die Ausprägung des (nicht verkalkten) Plaquevolumens, seine Lokalisierung und Dynamik scheinen als Merkmale der Vulnerabilität im Vergleich zur Fokussierung auf ein großes Atherom oder expansives Remodeling einzelner Plaques bedeutsamer zu sein. In den Leitlinien ist die koronare CT-Angiographie (CTA) sowohl bei den akuten Koronarsyndromen ohne ST-Hebung als auch den chronischen Koronarsyndromen an die erste Stelle gerückt – gleichberechtigt mit den klassischen bildgebenden Ischämietests. Unabhängig davon gewinnt die kardiale CT zunehmend an Bedeutung für die Therapieplanung von Vitien (insbesondere der Aorten- und Trikuspidalklappe), aber auch anderer struktureller Herzerkrankungen (z. B. Verschluss des linken Vorhofohrs, LAA).
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Affiliation(s)
- Axel Schmermund
- Cardioangiologisches Centrum Bethanien, CCB, Im Prüfling 23, 60389 Frankfurt am Main, Deutschland
| | - Philipp Breitbart
- Cardioangiologisches Centrum Bethanien, CCB, Im Prüfling 23, 60389 Frankfurt am Main, Deutschland
| | - Joachim Eckert
- Cardioangiologisches Centrum Bethanien, CCB, Im Prüfling 23, 60389 Frankfurt am Main, Deutschland
| | - Annett Magedanz
- Cardioangiologisches Centrum Bethanien, CCB, Im Prüfling 23, 60389 Frankfurt am Main, Deutschland
| | - Marco Schmidt
- Cardioangiologisches Centrum Bethanien, CCB, Im Prüfling 23, 60389 Frankfurt am Main, Deutschland
| | - Thomas Voigtländer
- Cardioangiologisches Centrum Bethanien, CCB, Im Prüfling 23, 60389 Frankfurt am Main, Deutschland
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12
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Bergmark BA, Morrow DA. Beyond the ISCHEMIA Trial: Revascularization for Stable Ischemic Heart Disease in Patients With High-Risk Coronary Anatomical Features. J Am Heart Assoc 2020; 10:e019974. [PMID: 33342221 PMCID: PMC7955493 DOI: 10.1161/jaha.120.019974] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Affiliation(s)
- Brian A Bergmark
- TIMI (Thrombolysis in Myocardial Infarction) Study Group Cardiovascular Division Brigham and Women's HospitalHarvard Medical School Boston MA
| | - David A Morrow
- TIMI (Thrombolysis in Myocardial Infarction) Study Group Cardiovascular Division Brigham and Women's HospitalHarvard Medical School Boston MA
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13
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Bainey KR, Alemayehu W, Welsh RC, Kumar A, King SB, Kirtane AJ. Long-Term Clinical Outcomes Following Revascularization in High-Risk Coronary Anatomy Patients With Stable Ischemic Heart Disease. J Am Heart Assoc 2020; 10:e018104. [PMID: 33342230 PMCID: PMC7955498 DOI: 10.1161/jaha.120.018104] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Background The ISCHEMIA (International Study of Comparative Health Effectiveness with Medical and Invasive Approaches) trial failed to show a reduction in hard clinical end points with an early invasive strategy in stable ischemic heart disease (SIHD). However, the influence of left main disease and high-risk coronary anatomy was left unaddressed. In a large angiographic disease-based registry, we examined the modulating effect of revascularization on long-term outcomes in anatomically high-risk SIHD. Methods and Results 9016 patients with SIHD with high-risk coronary anatomy (3 vessel disease with ≥70% stenosis in all 3 epicardial vessels or left main disease ≥50% stenosis [isolated or in combination with other disease]) were selected for study from April 1, 2002 to March 31, 2016. The primary composite of all-cause death or myocardial infarction (MI) was compared between revascularization versus conservative management. A total of 5487 (61.0%) patients received revascularization with either coronary artery bypass graft surgery (n=3312) or percutaneous coronary intervention (n=2175), while 3529 (39.0%) patients were managed conservatively. Selection for coronary revascularization was associated with improved all-cause death/MI as well as longer survival compared with selection for conservative management (Inverse Probability Weighted hazard ratio [IPW-HR] 0.62; 95% CI 0.58 to 0.66; P<0.001; IPW-HR 0.57; 95% CI 0.53-0.61; P<0.001, respectively). Similar risk reduction was noted with percutaneous coronary intervention (IPW-HR 0.64, 95% CI 0.59-0.70, P<0.001) and coronary artery bypass graft surgery (IPW-HR 0.61; 95% CI 0.57-0.66; P<0.001). Conclusions Revascularization in patients with SIHD with high-risk coronary anatomy was associated with improved long-term outcome compared with conservative therapy. As such, coronary anatomical profile should be considered when contemplating treatment for SIHD.
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Affiliation(s)
- Kevin R Bainey
- Canadian VIGOUR Center University of Alberta Edmonton Alberta Canada
| | | | - Robert C Welsh
- Canadian VIGOUR Center University of Alberta Edmonton Alberta Canada
| | - Arnav Kumar
- Emory University School of Medicine Atlanta GA
| | | | - Ajay J Kirtane
- New York-Presbyterian Hospital/Columbia University Medical Center New York NY
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