Use of drug-eluting stents in patients with coronary artery disease and renal insufficiency

Cardiovascular Outcomes in Patients on Hemodialysis following Drug-Eluting versus Bare-Metal Coronary Stents

Aim

This study sought to compare short- and long-term outcomes of drug-eluting stents (DESs) versus bare-metal stents (BMSs) implantation in patients with end-stage renal disease on hemodialysis (ESRD-HD) undergoing percutaneous coronary intervention (PCI).

Methods

Adult patients with ESRD-HD who underwent PCI at all nonfederal hospitals in Massachusetts between July 1, 2003, and September 30, 2007, were stratified based on the stent type placed at index hospitalization: DES or BMS. The primary outcome compared was a composite of all-cause death, myocardial infarction (MI), congestive heart failure (CHF), target vessel revascularization (TVR), and stroke at 30 days and one year.

Results

HD patients had a high mortality (31%) and were more likely to receive a DES than a BMS (77% versus 23%). Propensity score analysis of 2 : 1 matched DES (268) versus BMS (134) patients demonstrated the DES group to more likely have proximal LAD disease and a history of prior PCI. Conditional logistic regression analysis demonstrated no significant difference in the composite cardiovascular endpoint measured at 30 days (hazard ratio (HR) 1.09; 95% confidence interval (CI) 0.61–1.94) and one year (HR 1.03; 95% CI 0.68–1.57).

Conclusions

There were no significant differences in 30-day or 1-year major cardiovascular outcomes in HD patients undergoing PCI using the DES compared to the BMS in this high-mortality patient cohort.

Long-Term Percutaneous Coronary Intervention Outcomes of Patients with Chronic Kidney Disease in the Era of Second-Generation Drug-Eluting Stents

BACKGROUND

The following registry (Katowice-Zabrze retrospective registry) aimed to assess the influence of a chronic kidney disease (CKD) on long-term clinical outcomes in patients undergoing percutaneous coronary intervention (PCI) using either first-generation (DES-I) or second-generation (DES-II) drug-eluting stents.

METHODS

The study group consisted of 1,908 consecutive patients, of whom 331 (17.3%) had CKD. CKD was defined as an estimated glomerular filtration rate of <60 mL/min/m². We evaluated the major adverse cardiac and cerebral events (MACCE), i.e., the composite of death, myocardial infarction (MI), stroke, and target vessel revascularization at the 12-month follow-up.

RESULTS

CKD patients had a lower left ventricular ejection fraction and more often a history of MI and PCI. Coronary angiography revealed that multivessel coronary artery disease, intracoronary thrombus, and extensive calcifications were more frequent in patients with CKD. However, the SYNTAX score did not vary between patients with or without CKD. There was a higher rate of in-hospital bleedings requiring blood transfusion in patients with CKD. At the 1-year follow-up, MACCE (17.8 vs. 12.6%, HR = 1.46 [95% CI 1.05-2.03], p = 0.009) and death (8.4 vs. 2.3%, HR = 3.9 [95% CI 2.0-7.5], p < 0.001) were more often observed in CKD patients. Multivariable Cox analysis revealed that CKD was an independent risk predictor of death after PCI at the 1-year follow-up (HR = 2.1 [95% CI 1.2-3.6], p = 0.004). In comparison to DES-I, the use of DES-II did not decrease the adverse effect of CKD on MACCE.

CONCLUSION

CKD patients had an increased risk of in-hospital bleeding requiring blood transfusion and a higher risk of MACCE and death at the 12-month follow-up. The use of second-generation DES did not improve clinical outcomes in patients with CKD at the 12-month follow-up.

Cardiovascular risk factors profile in patients with acute coronary syndrome with particular reference to left ventricular ejection fraction

Background

Acute coronary syndrome (ACS) remains a leading cause of death in the United States. Numerous studies have shown that the degree of LV systolic dysfunction is a major if not the most important determinant of long-term outcome in ACS.

Objectives

To identify the most important risk factors and other clinical predictors which might have impact on left ventricular ejection fraction in patients with ACS.

Results

The total patients (299) admitted to our center from July, 2015 till December, 2015; with established diagnosis of ACS were classified in to two groups: Group I: 193 patients with impaired LVEF < 40% (64.5%), Group II: 106 patients with LVEF equal or > 40% (35.5%). The patients of group I were significant elderly compared to those of group II (60.9 ± 11.2 vs 56.9 ± 10.6; p = 0.002), had significant history of DM and CKD (66.3% and 31.1% VS 49.1% and 19.8%; p = 0.004 and 0.036 respectively), presented mainly with STEMI- ACS (51.3% VS 28.3% respectively; p < 0.001) with +v cardiac biomarker (troponin) (90.2% VS 66.0%; p < 0.001). Moreover, patients of group I had more significant ischemic MR compared to the patients of group II (24.9% VS 3.8% respectively; p < 0.001) with higher rate of LV thrombus discovered by echocardiography (25.4% VS 1.9%; p < 0.001). Extensive significant CAD disease was observed to be higher among patients of group I (69.4% VS 57.5%; p = 0.039) and those patients treated mainly with PCI revascularization therapy (68.9% VS 52.8%; p = 0.002) compared to patients of group II who mainly treated medically (34.9% VS 17.6 %; p < 0.001). Multiple logistic regression analysis demonstrated that DM (odd ratio (OR): 2.64, 95% confidence interval (CI): 1.45-4.79, P = 0.01), presence of significant ischemic MR (OR: 13.7, 95% CI:2.84-66.1, p = 0.001)and presence of significantly diseased coronary vessels (odd ratio (OR): 5.06, 95% confidence interval (CI): 1.14-22.6, P = 0.033,) all were independent predictors for significant LV dysfunction (LVEF < 40%) which predict poor outcome in ACS patients.

Conclusion

We concluded that DM, presence of significant ischemic MR, and increased number, severity of diseased coronaries all were independent predictors of LV dysfunction (LVEF < 40%) which is known to predict poor outcome. Identification of those risk predictors upon patient evaluation could be helpful to identify high risk-patients, in need of particular care, aggressive therapy and close follow-up to improve their poor outcome.

Dual Antiplatelet Therapy and Clinical Outcomes after Coronary Drug-Eluting Stent Implantation in Patients on Hemodialysis

BACKGROUND AND OBJECTIVES

We aimed to investigate the benefits and risks of dual antiplatelet therapy (DAPT) after coronary drug-eluting stent (DES) implantation in patients undergoing hemodialysis.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

A nested case-control analysis of patients on hemodialysis after receipt of DES and DAPT treatment was conducted using data from Taiwan's National Health Insurance Research Database for the period 2007-2011. Cases of myocardial infarction or death within 1 year after DES implantation were matched one-to-one with control patients. Odds ratios were calculated to compare DAPT continuation with discontinuation. Additionally, a propensity score-adjusted 6-month landmark cohort analysis was also conducted to evaluate the long-term benefits and risks of prolonged (>6 months) compared with ≤6 months of DAPT use. The primary outcomes were death and myocardial infarction. The secondary outcomes were ischemic stroke, revascularization, and major bleeding.

RESULTS

In the nested case-control analysis, patients who continued DAPT had a lower rate of death or myocardial infarction within 1 year after receipt of a DES (adjusted odds ratio, 0.54; 95% confidence interval, 0.36 to 0.81; P=0.003), whereas this association became statistically nonsignificant when compared with patients who discontinued DAPT for the period between 6 and 12 months after receipt of a DES (adjusted odds ratio, 1.51; 95% confidence interval, 0.75 to 3.04). In the propensity score-adjusted cohort analysis, >6 months of DAPT use was not associated with different primary or secondary outcomes than shorter-term use.

CONCLUSIONS

Our findings support that the clinical effectiveness of extended DAPT in a hemodialysis population may be tempered after 6 months post-DES implantation.

Coronary Revascularization in Patients with CKD Stage 5D: Pragmatic Considerations

Coronary revascularization decisions for patients with CKD stage 5D present a dilemma for clinicians because of high baseline risks of mortality and future cardiovascular events. This population differs from the general population regarding characteristics of coronary plaque composition and behavior, accuracy of noninvasive testing, and response to surgical and percutaneous revascularization, such that findings from the general population cannot be automatically extrapolated. However, this high-risk population has been excluded from all randomized trials evaluating outcomes of revascularization. Observational studies have attempted to address long-term outcomes after surgical versus percutaneous revascularization strategies, but inherent selection bias may limit accuracy. Compared with percutaneous strategies, surgical revascularization seems to have long-term survival benefit on the basis of observational data but associates with substantially higher short-term mortality rates. Percutaneous revascularization with drug-eluting and bare metal stents associates with a high risk of in-stent restenosis and need for future revascularization, perhaps contributing to the higher long-term mortality hazard. Off-pump coronary bypass surgery and the newest generation of drug-eluting stent platforms offer no definitive benefits. In this review, we address the nuances, complexities, and tradeoffs that clinicians face in determining the optimal method of coronary revascularization for this high-risk population.

Prevalence and impact of cardiovascular risk factors among patients presenting with acute coronary syndrome in the middle East

The authors explored the prevalence and impact of the cardiovascular risk factors (CVRFs) in patients presenting with acute coronary syndrome (ACS). During a five-month period in 2007, six adjacent Middle Eastern countries participated in the Gulf Registry of acute coronary events. CVRFs were identified on admission. Patients' characteristics and in-hospital outcomes were analyzed across the types of ACS. Among 6704 consecutive patients with ACS, 61% had non-ST elevation ACS (NSTEACS) and 39% had ST-elevation myocardial infarction (STEMI). Female sex, old age, diabetes mellitus, hypertension, dyslipidemia, and obesity were more prevalent in NSTEACS patients. STEMI patients were more likely to be smokers and less likely to be taking aspirin prior to the index admission. Chronic renal failure (CRF) and diabetes mellitus were independent predictors of in-hospital heart failure in NSTEACS, while CRF and hypertension were predictors of STEMI. Female sex and CRF were independent predictors of mortality in STEMI (odds ratio, 2.0; 95% confidence interval, 1.19-3.13 and odds ratio, 5.0; 95% confidence interval, 3.47-7.73, respectively). Assessment of the prevalence of CVRF in the acute coronary presentation is of important prognostic value for in-hospital morbidity and mortality. CVRF and its impact may differ according to ACS type, age, and sex. Coronary heart disease (CHD) is the leading cause of mortality and morbidity worldwide. To achieve a significant reduction in the prevalence of CHD, it is essential to adopt effective preventive strategies with adequate awareness of the epidemiology of cardiovascular risk factors (CVRFs).1 CVRFs include traditional and nontraditional factors. However, the US Preventive Services Task Force concluded that the evidence is insufficient to assess the balance of benefits and harms of using nontraditional risk factors.2,3 The World Health Organization has recognized obesity, hypertension, hypercholesterolemia, and smoking among the top10 traditional risk factors for premature death and morbidity.4 Since these risk factors are usually evident before developing CHD, knowledge of their prevalence in a given population allows the prediction of the likely burden of CHD.3 The American Heart Association has recognized many risk factors; some can be modified, treated, or controlled and some can not.5 The more risk factors present, the greater the likelihood of developing CHD. Currently, most reports for prevention of CHD are mainly derived from European centers and suggest that risk factors for CHD are varying from country to country.6 However, data from the Arab Middle East that evaluate the prevalence and impact of these risk factors in acute coronary events are scarce.4,7,8 We explore the prevalence of CVRFs in patients with acute coronary syndrome (ACS) who are living in the Arab Middle East and the impact of these factors on in-hospital heart failure (HF) and mortality. Copyright © 2011 Wiley Periodicals, Inc. The authors have no funding, financial relationships, or conflicts of interest to disclose.

The Management of Antiplatelet Therapy in Patients With Coronary Stents Undergoing Noncardiac Surgery

Whereas the development of coronary stents has been a major breakthrough in the treatment of coronary artery disease, stent thrombosis, associated with myocardial infarction and death, has introduced a new challenge in the care of patients with coronary stents undergoing noncardiac surgery. This review presents the authors’ recommendations regarding the optimal management of such patients. Elective surgery should be postponed for at least 6 weeks and optimally 3 months for a bare-metal stent and at least 1 year for a drug-eluting stent. On the other hand, managing a patient undergoing non-elective surgery is more difficult and necessitates a case-by-case assessment of bleeding risk versus thrombotic risk based on patient comorbidities, type of stents present, details of the coronary intervention, and type of surgical procedure. Patients with a risk of bleeding that outweighs the risk of stent thrombosis should discontinue at least clopidogrel, whereas all other patients should continue dual antiplatelet therapy throughout the perioperative period.

Hemodialysis is an independent predictor of coronary in-stent restenosis after paclitaxel eluting stent implantation

OBJECTIVE

A drug eluting stent is often used for high-risk patients with complications such as diabetes mellitus (DM) and hemodialysis (HD), however the factors to predict restenosis after paclitaxel-eluting stent (PES) placement have not been reported to date.

METHODS

Between May 2007 and August 2009, 165 consecutive patients (231 stents) received PES in our hospital. Stent diameter and length were determined by the use of intravascular ultrasound (IVUS). All patients continued to take 2 types of anti-platelet agents (aspirin and Clopidogrel or Ticlopidine). Ninety percent of the subjects received a follow-up coronary angiogram 6 months later.

RESULTS

Underlying diseases were hypertension in 75%, hyperlipidemia in 78% and DM in 60% (15% on insulin), and 14% of the subjects received HD. Eighty-three percent of the patients had orally taken Statin, 85% ACE/ARB and 68% had beta blockers. Mean length and diameter of PES were 21.6 ± 7.2 mm and 2.9 ± 0.3 mm, respectively. Target lesion revascularization (TLR) rate 6 months after PES placement was 14.6% overall. In HD patients TLR was 43%, hypertension 15.0%, hyperlipemia 12.4%, DM with oral medication 12.5%, DM with insulin 12.0%, respectively. In multivariate analysis, HD was an independent risk factor for TLR (p=0.0001, OR: 6.61, 95% C.I.: 2.34-18.6).

CONCLUSION

HD had the greatest influence on TLR after PES even though risk factors were well controlled. It is necessary to develop new PCI techniques and stents that are useful for HD patients.