Coronary Artery Bypass Grafting Versus Percutaneous Coronary Intervention for Multivessel Coronary Artery Disease: A One-Stage Meta-Analysis

Sex differences in survival following acute coronary syndrome with and without standard modifiable risk factors

PURPOSE

This meta-analysis investigates the sex differences in mortality risk between the acute coronary syndrome (ACS) population without standard modifiable risk factors (SMuRF-less) and those with at least one standard modifiable risk factor (SMuRF), and analyses mortality rates between males and females within the SMuRF-less cohort.

METHODS

The MEDLINE and Embase databases were searched for cohort studies with sex-stratified outcomes for SMuRF-less versus SMuRF patients with ACS till 15 December 2023. The analysis of variables reported in proportions was carried out by utilizing a meta-analysis with a generalized linear mixed model while continuous variables were analyzed by a meta-analysis of means, using an inverse variance method.

RESULTS

Eight studies were included in the current paper, with 82,395 SMuRF-less ACS patients and 607,558 SMuRF ACS patients. Excess in-hospital mortality found in SMuRF-less ACS, compared to those with SMuRFs, were only observed in females (RR 1.56, 95%CI 1.08-2.25, p = 0.029), but not in males (RR 1.59, 95%CI 0.90-2.80, p = 0.088). On longer follow-up, the 1- and 2-year post-ACS mortality rates were similar across the SMuRF-less and SMuRF cohorts, for both sexes. The subgroup analysis of SMuRF-less ACS individuals revealed that SMuRF-less females had higher in-hospital (RR 1.52, 95%CI 1.30-1.78, p = 0.002), 1-year (RR 1.51, 95%CI 1.34-1.71, p = 0.005) and 2-year mortality risks (RR 1.40, 95%CI 1.13-1.75, p = 0.016) compared to the SMuRF-less male counterparts.

CONCLUSION

Paradoxical excess mortality in SMuRF-less ACS, compared to those with SMuRFs, was only observed in females. Females without cardiovascular risk factors are at the highest risk of short- and medium-term mortality following ACS.

Outcomes of myocardial revascularization in patients with obesity and multivessel coronary artery disease

BACKGROUND

There is uncertainty regarding the best revascularization approach-whether coronary artery bypass grafting (CABG) or percutaneous coronary intervention (PCI)-for obese patients suffering from multi-vessel coronary artery disease.

RESULTS

406 patients with low and intermediate SYNTAX scores (SS) underwent PCI with drug-eluting stents (n = 200, 100 with SS ≤ 22, and 100 with SS 23-32) and CABG (n = 206, 100 with SS ≤ 22, and 106 with SS 23-32). Patients were also categorized by body mass index (BMI): normal weight (12%, 48 patients), overweight (41.6%, 169 patients), and obese (46.6%, 189 patients). The follow-up period averaged 9 ± 1.9 years. The endpoints of the study were as follows: major adverse cardiac and cerebrovascular events, a repeat revascularization, diminished left ventricular ejection fraction (LVEF), and high SS (≥ 33) observed over time. When comparing PCI and CABG in overweight individuals, the risk of myocardial infarction (MI) following PCI was greater than after CABG (Hazard Ratio [HR] 2.7, 95% Confidence Interval [CI] 1.1-6.7, p = 0.03). In patients with overweight and Class I obesity, CABG was associated with the risk of coronary atherosclerosis progression (SS ≥ 33) (HR 4.4, 95% CI 1.5-13, p = 0.009 and HR 4.9, 95% CI 1.9-12, p = 0.001, respectively); whereas PCI was connected with the likelihood of repeat revascularization (HR 2.7, 95% CI 1.6-4.55, p < 0.0001 and HR 2, 95% CI 1.3-3.1, p = 0.002, respectively). At the same time, for stented patients, Class III obesity was associated with the risk of repeat revascularization (HR 2.5, 95% CI 1.02-6, p = 0.044).

CONCLUSION

There were no significant weight-related impacts on long-term outcomes among patients who underwent surgery. Whereas in stented patients, Class III obesity was associated with the risk of repeat revascularization. When comparing PCI and CABG, for overweight and Class I obesity patients, CABG was associated with a likelihood of coronary atherosclerosis progression (SS ≥ 33), while PCI was linked to the risk of repeat revascularization. For overweight patients, CABG outperformed PCI in terms of the risk of MI. For other adverse events in patients of different weight categories, PCI and CABG did not reveal any significant benefits.

PCI vs. CABG in left main with multi-vessel coronary artery disease and diabetes: Case report

This case challenges the conventional preference for coronary artery bypass grafting (CABG) over percutaneous coronary intervention (PCI) in patients with diabetes, left main coronary artery disease (LMCAD) and multivessel disease. Current guidelines generally recommend CABG, especially in the context of LMCAD. However, our case involves a male patient with diabetes with LMCAD and extensive multivessel disease who was successfully treated with PCI, demonstrating a favorable outcome. Despite the high-risk profile, including a SYNTAX score of 28, the PCI approach was selected. This decision was supported by evidence suggesting comparable outcomes between PCI and CABG in similar patients. Our case highlights the potential of PCI as not just a viable, but potentially superior alternative in specific high-risk patients with diabetes, contrary to the prevailing belief in favor of CABG for all patients with left main involvement.

Epicardial Adipose Tissue Assessed by Computed Tomography and Echocardiography Are Associated With Adverse Cardiovascular Outcomes: A Systematic Review and Meta-Analysis

BACKGROUND

Epicardial adipose tissue (EAT) has garnered attention as a prognostic and risk stratification factor for cardiovascular disease. This study, via meta-analyses, evaluates the associations between EAT and cardiovascular outcomes stratified across imaging modalities, ethnic groups, and study protocols.

METHODS

Medline and Embase databases were searched without date restriction on May 2022 for articles that examined EAT and cardiovascular outcomes. The inclusion criteria were (1) studies measuring EAT of adult patients at baseline and (2) reporting follow-up data on study outcomes of interest. The primary study outcome was major adverse cardiovascular events. Secondary study outcomes included cardiac death, myocardial infarction, coronary revascularization, and atrial fibrillation.

RESULTS

Twenty-nine articles published between 2012 and 2022, comprising 19 709 patients, were included in our analysis. Increased EAT thickness and volume were associated with higher risks of cardiac death (odds ratio, 2.53 [95% CI, 1.17-5.44]; P=0.020; n=4), myocardial infarction (odds ratio, 2.63 [95% CI, 1.39-4.96]; P=0.003; n=5), coronary revascularization (odds ratio, 2.99 [95% CI, 1.64-5.44]; P<0.001; n=5), and atrial fibrillation (adjusted odds ratio, 4.04 [95% CI, 3.06-5.32]; P<0.001; n=3). For 1 unit increment in the continuous measure of EAT, computed tomography volumetric quantification (adjusted hazard ratio, 1.74 [95% CI, 1.42-2.13]; P<0.001) and echocardiographic thickness quantification (adjusted hazard ratio, 1.20 [95% CI, 1.09-1.32]; P<0.001) conferred an increased risk of major adverse cardiovascular events.

CONCLUSIONS

The utility of EAT as an imaging biomarker for predicting and prognosticating cardiovascular disease is promising, with increased EAT thickness and volume being identified as independent predictors of major adverse cardiovascular events.

REGISTRATION

URL: https://www.crd.york.ac.uk/prospero; Unique identifier: CRD42022338075.

Mortality, Cardiovascular, and Medication Outcomes in Patients With Myocardial Infarction and Underweight in a Meta-Analysis of 6.3 Million Patients

Although most of the current evidence on myocardial infarction focuses on obesity, there is growing evidence that patients who are underweight have unfavorable prognosis. This study aimed to explore the prevalence, clinical characteristics, and prognosis of this population at risk. Embase and Medline were searched for studies reporting outcomes in populations who were underweight with myocardial infarction. Underweight and normal weight were defined according to the World Health Organization criteria. A single-arm meta-analysis of proportions was used to estimate the prevalence of underweight in patients with myocardial infarction, whereas a meta-analysis of proportions was used to estimate the odds ratio of all-cause mortality, medications prescribed, and cardiovascular outcomes. Twenty-one studies involving 6,368,225 patients were included, of whom 47,866 were underweight. The prevalence of underweight in patients with myocardial infarction was 2.96% (95% confidence interval 1.96% to 4.47%). Despite having fewer classical cardiovascular risk factors, patients who were underweight had 66% greater hazard for mortality (hazard ratio 1.66, 95% confidence interval 1.44 to 1.92, p <0.0001). The mortality of patients who were underweight increased from 14.1% at 30 days to 52.6% at 5 years. Nevertheless, they were less likely to receive guideline-directed medical therapy. Relative to subjects with normal weight, Asian populations who were underweight had greater mortality risks than those of their Caucasian counterparts (p = 0.0062). In conclusion, in patients with myocardial infarction, those who were underweight tend to have poorer prognostic outcomes. A lower body mass index is an independent predictor of mortality, which calls for global efforts in addressing this modifiable risk factor in clinical practice guidelines.

Comparative Effectiveness of Coronary Artery Bypass Graft Surgery and Percutaneous Coronary Intervention for Patients With Coronary Artery Disease: A Meta-Analysis of Randomized Clinical Trials

Percutaneous coronary intervention (PCI) and coronary artery bypass graft (CABG) surgery are the options for revascularization in coronary artery disease (CAD). This meta-analysis aims to compare the efficacy of CABG and PCI for the management of patients with CAD. The meta-analysis was conducted as per the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. PubMed, Cochrane Library, and EMBASE were searched for relevant articles. The reference list of included articles was also searched manually for additional publications. Primary endpoints were cardiovascular mortality and all-cause mortality. Secondary endpoints included myocardial infarction, stroke, and revascularization. In total, 12 randomized control trials (RCTs) were included in this meta-analysis encompassing 9,941 patients (4,954 treated with CABG and 4,987 with PCI). The analysis showed that PCI was associated with a higher risk of all-cause mortality (risk ratio (RR) = 1.26, 95% confidence interval (CI) = 1.10-1.45) and revascularization (RR = 2.42, 95% CI = 1.82-3.21). However, no significant differences were reported between two arms regarding cardiovascular mortality (RR = 1.15, 95% CI = 0.96-1.39), myocardial infarction (RR = 1.17, 95% CI = 0.82-1.67), and stroke (RR = 0.64, 95% CI = 0.35-1.16). CABG was associated with a significant reduction in all-cause mortality and revascularization compared to PCI. However, no significant difference was reported in the risk of cardiovascular mortality, myocardial infarction, and stroke between the two groups.