Prognostic Value of Incomplete Revascularization after Percutaneous Coronary Intervention Following Acute Coronary Syndrome: Focus on CKD Patients

Progress in the Application of the Residual SYNTAX Score and Its Derived Scores

The residual SYNTAX score (rSS) is employed for the quantification of residual coronary lesions and to guide revascularization. rSS can be combined with other examinations to evaluate the severity of vascular disease and play an evaluative and guiding role in various scenarios. Furthermore, combining rSS with other indicators, benefits prognosis evaluation, and rSS-derived scores have been increasingly used in clinical practice. This article reviews the progress in the clinical application of rSS and its derived scores for complex coronary arteries and other aspects, based on relevant literature.

Chronic kidney disease's impact on revascularization and subsequent major adverse cardiovascular events in patients with chronic coronary syndrome

OBJECTIVE

To determine the impact of CKD on the completeness of revascularization and major adverse cardiovascular events (MACE) in patients with chronic coronary syndrome (CCS).

PATIENTS AND METHODS

The study enrolled 400 CCS patients who underwent revascularization by PCI. They were separated into two categories according to their eGFR levels: the control group: 200 patients with eGFR ≥60mL/min/1.73m2, and the CKD Group: 200 patients with eGFR< 60ml/min/1.73m.2 Patients were reclassified according to revascularization into complete and incomplete revascularization groups with one-year follow-up to assess the MACE.

RESULTS

CKD patients were significantly older (65.78 ± 6.41 vs. 56.70 ± 9.20 years, P=<0.001). They had higher syntax scores (P = 0.005), CIN (P = 0.001), all-cause mortality (P = 0.02), MACE (P = 0.037), and heart failure (P = 0.014). After reclassification according to revascularization. GFR was significantly reduced among patients with incomplete revascularization (51.08 ± 28.15 vs. 65.67 ± 26.62, respectively, P =<0.001). Repeated revascularization (P < 0.001), STEMI (P = 0.003), stent thrombosis (P = 0.015), MACE (P < 0.001), stroke (P < 0.001), and all-cause mortality (P < 0.001) were more prevalent among patients with incomplete revascularization. Multivariate regression analysis revealed eGFR (P = 0.001) and Syntax score (SS) (P=<0.001) as independent predictors of incomplete revascularization. The optimal eGFR cutoff value for predicting partial revascularization is 49.50mL/min/1.73m2, with 58.8% sensitivity and 69.3 % specificity.

CONCLUSION

Chronic kidney disease is associated with a higher syntax score and incomplete revascularization prevalence in CCS patients. Additionally, incomplete revascularization is associated with an increased incidence of major adverse cardiac events. In patients with CCS, CKD predicts partial revascularization and subsequent MACE.

Effect of glomerular filtration rate in patients undergoing percutaneous coronary intervention: A systematic review and meta-analysis

BACKGROUND

Through meta-analysis of the relationship between glomerular filtration rate and major adverse cardiovascular events (MACE) after percutaneous coronary intervention (PCI), we studied the impact of glomerular filtration rate on the prognosis of PCI.

METHODS

We collected literature on the incidence of MACE in patients with chronic kidney disease (CKD; estimated glomerular filtration rate < 60 mL/minute/1.73 m2) and patients with nonchronic kidney disease undergoing PCI. The search period was from January 1, 2000, to November 1, 2021. The searched databases included CNKI, Chinese Wanfang Data, China Biology Medicine disc, Web of Science, PubMed, and Cochrane Library. We used subgroup analysis and meta-regression to assess heterogeneity.

RESULTS

Twenty-one eligible studies were included, with 46,255 samples included, 4903 cases of MACE (10.6%), and patients with CKD had a higher risk of MACE after PCI (Risk ratios = 1.67; 95% confidence interval: 1.51-1.85). Multivariate meta regression results show that heterogeneity is related to region. The risk of MACEs in patients with CKD is different in different regions, and North America has the lowest risk, with an risk ratios value of 1.21 (95% confidence interval: 1.08-1.35).

CONCLUSION

Chronic kidney disease will increase the probability of MACE in patients with myocardial infarction after PCI and affect the prognosis of PCI. Therefore, clinical attention should be given to assessing glomerular filtration rate effects while treating patients with myocardial infarction with the PCI procedure.

Long-Term Follow-Up of Contrast-Induced Acute Kidney Injury: A Study from a Developing Country

Introduction

Contrast-induced acute kidney injury (CI-AKI) is a worldwide known complication related to the use of contrast media with either imaging or angiography; it carries its own complications and effect on both morbidity and mortality; early identification of patients at risk and addressing modifiable risk factors may help reducing risk for this disease and its complications.

Methods

This was a prospective observational study, where all patients admitted for cardiac catheterization between June 2015 and January 2016 were evaluated for CI-AKI. There were two study groups: contrast-induced acute kidney injury (CI-AKI) group, and noncontrast-induced acute kidney injury (non-CI-AKI) group.

Results

Patients (n = 202) were included and followed up for 4 years. Death and development of chronic kidney disease (CKD) need for another revascularization were the end points. The incidence of CI-AKI was 14.8%.In univariate analysis, age (P = 0.016) and serum albumin at admission (P = 0.001) were statistically significant predictors of overall death. Age (P = 0.002), HTN (P = 0.002), DM (P = 0.02), and the use of diuretics (P = 0.001) had a statistically significant impact on eGFR. The rate of recatheterization was not statistically significant between the two groups (61 (35.5%) for the non-CI-AKI vs. 12 (40%) for the other group; P = 0.63). Some inflammatory markers (NGAL P = 0.06, IL-19 P = 0.08) and serum albumin at admission P = 0.07 had a trend toward a statistically significant impact on recatheterization. Death (P = 0.66) and need for recatheterization (P = 0.63) were not statistically different between the 2 groups, while the rate of eGFR decline in for the CI-AKI was significant (P = 0.004).

Conclusion

CI-AKI is a common complication post percutaneous catheterization (PCI), which may increase the risk for CKD, but not death or the need for recatheterization. Preventive measures must be taken early to decrease the morbidity.

Composite outcome measurement in clinical research: the triumph of illusion over reality?

Composite measures that combine different types of indicators are widely used in medical research; to evaluate health systems, as outcomes in clinical trials and patient-reported outcome measurement. The potential advantages of such indices are clear. They are used to summarise complex data and to overcome the problem of evaluating new interventions when the most important outcome is rare or likely to occur far in the future. However, many scientists question the value of composite measures, primarily due to inadequate development methodology, lack of transparency or the likelihood of producing misleading results. It is argued that the real problems with composite measurement are related to their failure to take account of measurement theory and the absence of coherent theoretical models that justify the addition of the individual indicators that are combined into the composite index. All outcome measures must be unidimensional if they are to provide meaningful data. They should also have dimensional homogeneity. Ideally, a specification equation should be developed that can predict accurately how organisations or individuals will score on an index, based on their scores on the individual indicators that make up the measure. The article concludes that composite measures should not be used as they fail to apply measurement theory and, consequently, produce invalid and misleading scores.

TicagRelor Or Clopidogrel in severe or terminal chronic kidney patients Undergoing PERcutaneous coronary intervention for acute coronary syndrome: The TROUPER trial

Chronic kidney disease (CKD) is associated with an increased risk of acute coronary syndrome (ACS) and cardiovascular death. CKD patients suffering from ACS are exposed to an increased risk of thrombotic recurrences and a higher bleeding rate than patients with normal renal function. However, CKD patients are excluded or underrepresented in clinical trials. Therefore, determining the optimal antiplatelet strategy in this population is of utmost importance. We designed the TicagRelor Or Clopidogrel in severe or terminal chronic kidney patients Undergoing PERcutaneous coronary intervention for acute coronary syndrome (TROUPER) trial: a prospective, controlled, multicenter, randomized trial to investigate the optimal P2Y12 antagonist in CKD patients with ACS. Patients with stage ≥3b CKD are eligible if the diagnosis of ACS is made and invasive strategy scheduled. Patients are randomized 1:1 between a control group with a 600-mg loading dose of clopidogrel followed by a 75-mg/d maintenance dose for 1 year and an experimental group with a 180-mg loading dose of ticagrelor followed by a 90-mg twice daily maintenance dose for the same duration. The primary end point is defined by the rate of major adverse cardiovascular events, including death, myocardial infarction, urgent revascularization, and stroke at 1 year. Safety will be evaluated by the bleeding rate (Bleeding Academic Research Consortium). To demonstrate the superiority of ticagrelor on major adverse cardiovascular events, we calculated that 508 patients are required. The aim of the TROUPER trial is to compare the efficacy of ticagrelor and clopidogrel in stage >3b CKD patients presenting with ACS and scheduled for an invasive strategy. RCT# NCT03357874.

Residual SYNTAX Score Is Associated With Contrast-Induced Nephropathy in Patients With Non-ST Segment Elevation Myocardial Infarction With Preserved LVEF

The purpose of this study is to investigate the relation between residual SYNTAX score (rSS) and contrast-induced nephropathy (CIN) development in patients with non-ST segment elevation myocardial infarction (NSTEMI) with normal or near-to-normal left ventricular ejection fraction (LVEF) who underwent percutaneous coronary intervention (PCI). A total of 306 patients who underwent PCI with NSTEMI were included in our study. SYNTAX scores were calculated for the periods before and after PCI. Patients were divided into 2 groups as developed CIN following PCI (CIN +) and patients did not (CIN -). Fifty-four (17.6%) of patients who were included in the study developed CIN. Age (P = .001) and rSS (P = .002) were significantly higher and LVEF was lower (P = .034) in the CIN (+) group. Age (P = .031, odds ratio [OR]: 1.031, 95% CI, 1.003-1.059) and rSS (P = .04, OR: 1.036, 95% CI, 1.002-1.071) were independent predictors for CIN. In receiver operating characteristic analyses, when the cutoff value of rSS was taken as 3.5, it determined CIN with 79% sensitivity and 65% specificity. Contrast-induced nephropathy may develop more frequently in patients with increased rSS value. The rSS may be useful to follow-up these patients for CIN development.

Anesthetic Agents and Cardiovascular Outcomes of Noncardiac Surgery after Coronary Stent Insertion

Patients undergoing noncardiac surgery after coronary stent implantation are at an increased risk of thrombotic complications. Volatile anesthetics are reported to have organ-protective effects against ischemic injury. Propofol has an anti-inflammatory action that can mitigate ischemia-reperfusion injury. However, the association between anesthetic agents and the risk of major adverse cardiovascular and cerebral event (MACCE) has never been studied before. In the present study, a total of 1630 cases were reviewed. Four different propensity score matchings were performed to minimize selection bias (propofol-based total intravenous anesthesia (TIVA) vs. volatile anesthetics; TIVA vs. sevoflurane; TIVA vs. desflurane; and sevoflurane vs. desflurane). The incidence of MACCE in these four propensity score-matched cohorts was compared. As a sensitivity analysis, a multivariable logistic regression analysis was performed to identify independent predictors for MACCE during the postoperative 30 days both in total and matched cohorts (TIVA vs. volatile agent). MACCE occurred in 6.0% of the patients. Before matching, there was a significant difference in the incidence of MACCE between TIVA and sevoflurane groups (TIVA 5.1% vs. sevoflurane 8.2%, p = 0.006). After matching, there was no significant difference in the incidence of MACCE between the groups of any pairs (TIVA 6.5% vs. sevoflurane 7.7%; p = 0.507). The multivariable logistic regression analysis revealed no significant association of the volatile agent with MACCE (odds ratio 1.48, 95% confidence interval 0.92–2.37, p = 0.104). In conclusion, the choice of anesthetic agent for noncardiac surgery did not significantly affect the development of MACCE in patients with previous coronary stent implantation. However, further randomized trials are needed to confirm our results.

Chronic Kidney Disease Has a Graded Association with Death and Cardiovascular Outcomes in Stable Coronary Artery Disease: An Analysis of 21,911 Patients from the CLARIFY Registry

: Chronic kidney disease (CKD) is associated with an increased cardiovascular risk in a broad spectrum of populations. However, the risk associated with a reduced estimated glomerular filtration rate (eGFR) in patients with stable coronary artery disease receiving standard care in the modern era, independently of baseline cardiovascular disease, risk factors, and comorbidities, remains unclear. We analyzed data from 21,911 patients with stable coronary artery disease, enrolled in 45 countries between November 2009 and July 2010 in the CLARIFY registry. Patients with abnormal renal function were older, with more comorbidities, and received slightly lower-although overall high-rates of evidence-based secondary prevention therapies than patients with normal renal function. The event rate of patients with CKD stage 3b or more (eGFR <45 mL/min/1.73 m2) was much higher than that associated with any comorbid condition. In a multivariable adjusted Cox proportional hazards model, lower eGFR was independently associated with a graded increased risk of cardiovascular mortality, with adjusted HRs (95% CI) of 0.98 (0.81-1.18), 1.31 (1.05-1.63), 1.77 (1.38-2.27), and 3.12 (2.25-4.33) for eGFR 60-89, 45-59, 30-44, and <30 mL/min/1.73 m2, compared with eGFR ≥90 mL/min/1.73 m2. A strong graded independent relationship exists between the degree of CKD and cardiovascular mortality in this large cohort of patients with chronic coronary artery disease, despite high rates of secondary prevention therapies. Among clinical risk factors and comorbid conditions, CKD stage 3b or more is associated with the highest cardiovascular mortality.