Patients' preferences for coronary revascularization: a systematic review

Merging machine learning and patient preference: a novel tool for risk prediction of percutaneous coronary interventions

BACKGROUND AND AIMS

Predicting personalized risk for adverse events following percutaneous coronary intervention (PCI) remains critical in weighing treatment options, employing risk mitigation strategies, and enhancing shared decision-making. This study aimed to employ machine learning models using pre-procedural variables to accurately predict common post-PCI complications.

METHODS

A group of 66 adults underwent a semiquantitative survey assessing a preferred list of outcomes and model display. The machine learning cohort included 107 793 patients undergoing PCI procedures performed at 48 hospitals in Michigan between 1 April 2018 and 31 December 2021 in the Blue Cross Blue Shield of Michigan Cardiovascular Consortium (BMC2) registry separated into training and validation cohorts. External validation was conducted in the Cardiac Care Outcomes Assessment Program database of 56 583 procedures in 33 hospitals in Washington.

RESULTS

Overall rate of in-hospital mortality was 1.85% (n = 1999), acute kidney injury 2.51% (n = 2519), new-onset dialysis 0.44% (n = 462), stroke 0.41% (n = 447), major bleeding 0.89% (n = 942), and transfusion 2.41% (n = 2592). The model demonstrated robust discrimination and calibration for mortality {area under the receiver-operating characteristic curve [AUC]: 0.930 [95% confidence interval (CI) 0.920-0.940]}, acute kidney injury [AUC: 0.893 (95% CI 0.883-0.903)], dialysis [AUC: 0.951 (95% CI 0.939-0.964)], stroke [AUC: 0.751 (95%CI 0.714-0.787)], transfusion [AUC: 0.917 (95% CI 0.907-0.925)], and major bleeding [AUC: 0.887 (95% CI 0.870-0.905)]. Similar discrimination was noted in the external validation population. Survey subjects preferred a comprehensive list of individually reported post-procedure outcomes.

CONCLUSIONS

Using common pre-procedural risk factors, the BMC2 machine learning models accurately predict post-PCI outcomes. Utilizing patient feedback, the BMC2 models employ a patient-centred tool to clearly display risks to patients and providers (https://shiny.bmc2.org/pci-prediction/). Enhanced risk prediction prior to PCI could help inform treatment selection and shared decision-making discussions.

Do the Few Dictate Care for the Many? Revascularisation Considerations That Go Beyond the Guidelines

The burden of coronary artery disease (CAD) is large and growing, commonly presenting with comorbidities and older age. Patients may benefit from coronary revascularisation with percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG), yet half of patients with CAD who would benefit from revascularisation fall outside the eligibility criteria of trials to date. As such, the choice of revascularisation procedures varies depending on the CAD anatomy and complexity, surgical risk and comorbidities, the patient's preferences and values, and the treating team's expertise. The recent American guidelines on coronary revascularisation are comprehensive in describing recommendations for PCI, CABG, or conservative management in patients with CAD. However, individual challenging patient presentations cannot be fully captured in guidelines. The aim of this narrative review is to summarise common clinical scenarios that are not sufficiently described by contemporary clinical guidelines and trials in order to inform heart team members and trainees about the nuanced considerations and available evidence to manage such cases. We discuss clinical cases that fall beyond the current guidelines and summarise the relevant evidence evaluating coronary revascularisation for these patients. In addition, we highlight gaps in knowledge based on a lack of research (eg, ineligibility of certain patient populations), underrepresentation in research (eg, underenrollment of female and non-White patients), and the surge in newer minimally invasive and hybrid techniques. We argue that ultimately, evidence-based medicine, patient preference, shared decision making, and effective heart team communications are necessary to best manage complex CAD presentations potentially benefitting from revascularisation with CABG or PCI.

Nurse-led intervention in the management of patients with cardiovascular diseases: a brief literature review

Coronary artery disease (CAD) is one among the major causes of mortality in patients all around the globe. It has been reported by the World Health Organization (WHO) that approximately 80% of cardiovascular diseases could be prevented through lifestyle modifications. Management of CAD involves the prevention and control of cardiovascular risk factors, invasive and non-invasive treatments including coronary revascularizations, adherence to proper medications and regular outpatient follow-ups. Nurse-led clinics were intended to mainly provide supportive, educational, preventive measures and psychological support to the patients, which were completely different from therapeutic clinics. Our review focuses on the involvement and implication of nurses in the primary and secondary prevention and management of cardiovascular diseases. Nurses have a vital role in Interventional cardiology. They also have major roles during the management of cardiac complications including congestive heart failure, atrial fibrillation and heart transplantation. Today, the implementation of a nurse-led tele-consultation strategy is also gaining positive views. Therefore, a nurse-led intervention for the management of patients with cardiovascular diseases should be implemented in clinical practice. Based on advances in therapy, more research should be carried out to further investigate the effect of nurse-led clinics during the long-term treatment and management of patients with cardiovascular diseases.

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

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.

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

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.

Methods to Summarize Discrete-Choice Experiments in a Systematic Review: A Scoping Review

BACKGROUND AND OBJECTIVE

Systematic reviews of discrete-choice experiments (DCEs) are being increasingly conducted. The objective of this scoping review was to identify and describe the methodologies that have been used to summarize results across DCEs.

METHODS

We searched the electronic databases MEDLINE and EMBASE from inception to March 18, 2021, to identify English-language systematic reviews of patient preferences that included at least two DCEs and extracted data on attribute importance. The methods used to summarize results across DCEs were classified into narrative, semi-quantitative, and quantitative (meta-analytic) approaches and compared. Approaches to characterize the extent of preference heterogeneity were also described.

RESULTS

From 7362 unique records, we identified 54 eligible reviews from 2010 to Mar 2021, across a broad range of health conditions. Most (83%) used a narrative approach to summarize findings of DCEs, often citing differences in studies as the reason for not formally pooling findings. Semi-quantitative approaches included summarizing the frequency of the most important attributes, the frequency of attribute statistical significance, or tabulated comparisons of attribute importance for each pair of attributes. One review conducted a meta-analysis using the maximum acceptable risk. While reviews often commented on the heterogeneity of patient preferences, few (6%) addressed this systematically across studies.

CONCLUSION

While not commonly used, several semi-quantitative and one quantitative approach for synthesizing results of DCEs were identified, which may be useful for generating summary estimates across DCEs when appropriate. Further work is needed to assess the validity and usefulness of these approaches.

Direct kidney injury or lower extremity ischemia induced indirect kidney injury: Which one is more harmful for kidneys?

OBJECTIVES

The aim of this study was to investigate and compare the severity of kidney damage following lower limb ischemia-reperfusion and direct kidney ischemia-reperfusion.

METHODS

Thirty Sprague Dawley male rats were randomly divided into three groups; lower extremity ischemia-reperfusion group (Group 2), renal ischemia-reperfusion group (Group 3) and control (anesthesia and median laparotomy only) (Group 1). In group 3, 1-h ischemia was performed on the kidney and in group 2, 1-h ischemia was performed on the left lower extremity. This procedure was followed by reperfusion for 24 h. Renal tissues were removed after the reperfusion period and the groups were evaluated for glutathioneperoxidase activity, malondialdehyde and GSH levels, and furthermore, their histolopathological scores were calculated.

RESULTS

Renal malondialdehyde levels were significantly higher in Group 2 and Group 3 than they were in the Control group. There was no significant difference in renal malondialdehyde levels between Group 2 and Group 3. Kidney glutathione (GSH) levels were statistically lower in Group 2 and Group 3 than in the Control group. No statistically significant difference was found between Group 2 and Group 3 regarding their GSH levels. In histological evaluation, there was no statistically significant difference between Group 2 and Group 3 in terms of kidney damage score.

CONCLUSIONS

This study has identified that lower extremity ischemia induces remote kidney damage with similar features to kidney injury, occurring after direct kidney ischemia-reperfusion.

Patients' Preferences after Recurrent Coronary Narrowing: Discrete Choice Experiments

Fundamento:

Selecionar a estratégia de tratamento ideal para a revascularização coronária é um desafio. Um desfecho crucial a ser considerado no momento dessa escolha é a necessidade de refazer a revascularização, uma vez que ela se torna muito mais frequente após a intervenção coronária percutânea (ICP) do que após a cirurgia de revascularização do miocárdio (CRM).

Objetivo:

Pretende-se, com este estudo, trazer reflexões acerca das preferências dos pacientes pelas estratégias de revascularização sob a perspectiva de pacientes que tiveram que refazer a revascularização.

Métodos:

Selecionamos uma amostra de pacientes que haviam sido submetidos à ICP e hospitalizados para refazer a revascularização coronária e elicitamos suas preferências por nova ICP ou CRM. Morte perioperatória, mortalidade a longo prazo, infarto do miocárdio e repetir a revascularização foram utilizados para a construção de cenários a partir da descrição de tratamentos hipotéticos que foram rotulados como ICP ou CRM. A ICP era sempre apresentada como a opção com menor incidência de morte perioperatória e maior necessidade de se refazer o procedimento. O modelo logístico condicional foi empregado para analisar as escolhas dos pacientes, utilizando-se o software R. Valores de p <0,05 foram considerados estatisticamente significativos.

Resultados:

Ao todo, 144 pacientes participaram, a maioria dos quais (73,7%) preferiram a CRM à ICP (p < 0,001). Os coeficientes de regressão foram estatisticamente significativos para o rótulo ICP, mortalidade a longo prazo da ICP, morte perioperatória da CRM, mortalidade a longo prazo da CRM e refazer a CRM. O rótulo ICP foi o parâmetro mais importante (p < 0,05).

Conclusão:

A maioria dos pacientes que enfrentam a necessidade de refazer a revascularização coronária rejeitam uma nova ICP, com base em níveis realistas de riscos e benefícios. Incorporar as preferências dos pacientes à estimativa do risco-benefício e às recomendações de tratamento poderia melhorar o cuidado centrado no paciente.

Trends in Guideline-Driven Revascularization in Diabetic Patients with Multivessel Coronary Heart Disease

In diabetes patients with chronic ≥3 vessel disease, coronary artery bypass grafting (CABG) holds a class I recommendation in the American College of Cardiology and American Heart Association (ACC/AHA) 2011 guidelines, and this classification has not changed to date. Much of the literature has focused upon whether CABG or percutaneous coronary intervention (PCI) produces better outcomes; there is a paucity of data comparing the odds of receiving these procedures. A secondary analysis was conducted in a de-identified database comprised of 30,482 patients satisfying the entry criteria. Odds of occurrence (CABG, PCI) were determined as the binary dependent variable in period 1, (17 October 2009 through 31 December 2011), and period 2 (1 January 2013 through 16 March 2015), before and after the 2011 guidelines, while controlling for gender, ethnicity/race, and ischemic heart disease as covariates. The odds of performing CABG rather than PCI in period 2 were not statistically significantly different than in period 1 (p = 0.400). The logistic regression model chi-square statistic was statistically significant, with χ₂ (7) = 308.850, p < 0.0001. The Wald statistic showed that ethnicity/race (African American, Caucasian, Hispanic and Other), gender, and heart disease contributed significantly to the prediction model with p < 0.05, but ethnicity ‘Unknown’ did not. The odds of CABG versus PCI in period 2 were 0.98 times those in period 1 95% confidence interval (CI) = (0.925, 1.032), statistically controlling for covariates. There was no significant rise in the odds of undergoing a CABG among this dataset of high-risk patients with diabetes and multivessel coronary heart disease. Modern practice has evolved regarding patient choice and additional variables that impact the final revascularization method employed. The degree to which odds of occurrence of procedures are a reliable surrogate for provider compliance with guidelines remains uncertain.