Coronary chronic total occlusions and mortality in patients with ventricular tachyarrhythmias

Evaluation and management of patients with coronary chronic total occlusions considered for revascularisation. A clinical consensus statement of the European Association of Percutaneous Cardiovascular Interventions (EAPCI) of the ESC, the European Association of Cardiovascular Imaging (EACVI) of the ESC, and the ESC Working Group on Cardiovascular Surgery

Chronic total occlusions (CTOs) of coronary arteries can be found in the context of chronic or acute coronary syndromes; sometimes they are an incidental finding in those apparently healthy individuals undergoing imaging for preoperative risk assessment. Recently, the invasive management of CTOs has made impressive progress due to sophisticated preinterventional assessment, including advanced non-invasive imaging, the availability of novel and dedicated tools for CTO percutaneous coronary intervention (PCI), and experienced interventionalists working in specialised centres. Thus, it is crucial that referring physicians who see patients with CTO be aware of recent developments and of the initial evaluation requirements for such patients. Besides a careful history and clinical examination, electrocardiograms, exercise tests, and non-invasive imaging modalities are important for selecting the patients most suitable for CTO PCI, while others may be referred to coronary artery bypass graft or optimal medical therapy only. While CTO PCI improves angina and reduces the use of antianginal drugs in patients with symptoms and proven ischaemia, hibernation and/or wall motion abnormalities at baseline or during stress, the effect of CTO PCI on major cardiovascular events is still controversial. This clinical consensus statement specifically focuses on referring physicians, providing a comprehensive algorithm for the preinterventional evaluation of patients with CTO and the current evidence for the clinical effectiveness of the procedure. The proposed care track has been developed by members and with the support of the European Association of Percutaneous Cardiovascular Interventions (EAPCI), the European Association of Cardiovascular Imaging (EACVI), and the European Society of Cardiology (ESC) Working Group on Cardiovascular Surgery.

Prognostic Value of Cardiac Troponin I in Patients with Ventricular Tachyarrhythmias

Besides the diagnostic role in acute myocardial infarction, cardiac troponin I levels (cTNI) may be increased in various other clinical conditions, including heart failure, valvular heart disease and sepsis. However, limited data are available regarding the prognostic role of cTNI in the setting of ventricular tachyarrhythmias. Therefore, the present study sought to assess the prognostic impact of cTNI in patients with ventricular tachyarrhythmias (i.e., ventricular tachycardia (VT) and fibrillation (VF)) on admission. A large retrospective registry was used, including all consecutive patients presenting with ventricular tachyarrhythmias from 2002 to 2015. The prognostic impact of elevated cTNI levels was investigated for 30-day all-cause mortality (i.e., primary endpoint) using Kaplan–Meier, receiver operating characteristic (ROC), multivariable Cox regression analyses and propensity score matching. From a total of 1104 patients with ventricular tachyarrhythmias and available cTNI levels on admission, 46% were admitted with VT and 54% with VF. At 30 days, high cTNI was associated with the primary endpoint (40% vs. 22%; log rank p = 0.001; HR = 2.004; 95% CI 1.603–2.505; p = 0.001), which was still evident after multivariable adjustment and propensity score matching (30% vs. 18%; log rank p = 0.003; HR = 1.729; 95% CI 1.184–2.525; p = 0.005). Significant discrimination of the primary endpoint was especially evident in VT patients (area under the curve (AUC) 0.734; 95% CI 0.645–0.823; p = 0.001). In contrast, secondary endpoints, including all-cause mortality at 30 months and a composite arrhythmic endpoint, were not affected by cTNI levels. The risk of cardiac rehospitalization was lower in patients with high cTNI, which was no longer observed after propensity score matching. In conclusion, high cTNI levels were associated with increased risk of all-cause mortality at 30 days in patients presenting with ventricular tachyarrhythmias.

Switching From Proximal to Distal Radial Artery Access for Coronary Chronic Total Occlusion Recanalization

Background

Distal radial access (DRA) was recently introduced in the hopes of improving patient comfort by allowing the hand to rest in a more ergonomic position throughout percutaneous coronary interventions (PCI), and potentially to further reduce the rate of complications (mainly radial artery occlusion, [RAO]). Its safety and feasibility in chronic total occlusion (CTO) PCI have not been thoroughly explored, although the role of DRA could be even more valuable in these procedures.

Methods

From 2016 to 2021, all patients who underwent CTO PCI in 3 Hungarian centers were included, divided into 2 groups: one receiving proximal radial access (PRA) and another DRA. The primary endpoints were the procedural and clinical success and vascular access-related complications. The secondary endpoints were major adverse cardiac and cerebrovascular events (MACCE) and procedural characteristics (volume of contrast, fluoroscopy time, radiation dose, procedure time, hospitalization time).

Results

A total of 337 consecutive patients (mean age 64.6 ± 9.92 years, 72.4% male) were enrolled (PRA = 257, DRA = 80). When compared with DRA, the PRA group had a higher prevalence of smoking (53.8% vs. 25.7%, SMD = 0.643), family history of cardiovascular disease (35.0% vs. 15.2%, SMD = 0.553), and dyslipidemia (95.0% vs. 72.8%, SMD = 0.500). The complexity of the CTOs was slightly higher in the DRA group, with higher degrees of calcification and tortuosity (both SMD >0.250), more bifurcation lesions (45.0% vs. 13.2%, SMD = 0.938), more blunt entries (67.5% vs. 47.1%, SMD = 0.409). Contrast volumes (median 120 ml vs. 146 ml, p = 0.045) and dose area product (median 928 mGy×cm² vs. 1,300 mGy×cm², p < 0.001) were lower in the DRA group. Numerically, local vascular complications were more common in the PRA group, although these did not meet statistical significance (RAO: 2.72% vs. 1.25%, p = 0.450; large hematoma: 0.72% vs. 0%, p = 1.000). Hospitalization duration was similar (2.5 vs. 3.0 days, p = 0.4). The procedural and clinical success rates were comparable through DRA vs. PRA (p = 0.6), moreover, the 12-months rate of MACCE was similar across the 2 groups (9.09% vs. 18.2%, p = 0.35).

Conclusion

Using DRA for complex CTO interventions is safe, feasible, lowers radiation dose and makes dual radial access more achievable. At the same time, there was no signal of increased risk of periprocedural or long-term adverse outcomes.

Management of refractory angina: an update

Despite the use of anti-anginal drugs and/or percutaneous coronary interventions (PCI) or coronary artery bypass grafting, the proportion of patients with coronary artery disease who have daily or weekly angina ranges from 2% to 24%. Refractory angina refers to long-lasting symptoms (for >3 months) due to established reversible ischaemia, which cannot be controlled by escalating medical therapy with the use of 2nd- and 3rd-line pharmacological agents, bypass grafting, or stenting. While there is uncertain prognostic benefit, the treatment of refractory angina is important to improve the quality of life of the patients affected. This review focuses on conventional pharmacological approaches to treating refractory angina, including guideline directed drug combination and dosages. The symptomatic and prognostic impact of advanced and novel revascularization strategies such as chronic total occlusion PCI, transmyocardial laser revascularization, coronary sinus occlusion, radiation therapy for recurrent restenosis, and spinal cord stimulation are also covered and recommendations of the 2019 ESC Guidelines on the Diagnosis and Management of Chronic Coronary Syndromes discussed. Finally, the potential clinical use of current angiogenetic and stem cell therapies in reducing ischaemia and/or pain is evaluated.

Late Survival Benefit of Percutaneous Coronary Intervention Compared With Medical Therapy in Patients With Coronary Chronic Total Occlusion: A 10-Year Follow-Up Study

Background

As an initial treatment strategy, percutaneous coronary intervention (PCI) for coronary chronic total occlusion (CTO) did not show midterm survival benefits compared with optimal medical therapy (OMT). We sought to evaluate the benefit of PCI compared with OMT in patients with CTO over extended long‐term follow‐up.

Methods and Results

Between March 2003 and February 2012, 2024 patients with CTO were enrolled in a single‐center registry and followed for ≈10 years. We excluded patients with CTO who underwent coronary artery bypass graft (n=477) and classified patients into the CTO‐PCI group (n=883) or OMT group (n=664) according to initial treatment strategy. Patients with multivessel disease received PCI for obstructive non‐CTO lesions in both groups. In the CTO‐PCI group, 699 patients (79.2%) underwent successful revascularization. The CTO‐PCI group had a lower 10‐year rate of cardiac death (10.4% versus 22.3%; hazard ratio [HR], 0.44 [95% CI, 0.32–0.59]; P<0.001) than the OMT group. After propensity score matching analyses, the CTO‐PCI group had a lower 10‐year rate of cardiac death (13.6% versus 20.8%; HR, 0.64 [95% CI, 0.45–0.91]; P=0.01) than the OMT group. The relative reduction in cardiac death at 10 years was mainly driven by a relative reduction between 3 and 10 years (8.3% versus 16.6%; HR, 0.43 [95% CI, 0.27–0.71]; P<0.001) but not at 3 years (5.7% versus 5.0%; HR, 1.12 [95% CI, 0.63–2.00]; P=0.71). The beneficial effects of CTO‐PCI were consistent among subgroups.

Conclusions

As an initial treatment strategy, CTO‐PCI might reduce late cardiac death compared with OMT in patients with CTO. Extended follow‐up of randomized trials may confirm the findings of the present study.

Prognostic Impact of Percutaneous Coronary Intervention of Chronic Total Occlusion in Acute and Periprocedural Myocardial Infarction

Coronary chronic total occlusion (CTO) has gained increasing clinical attention as the most advanced form of coronary artery disease. Prior studies already indicated a clear association of CTO with adverse clinical outcomes, especially in patients with acute myocardial infarction (AMI) and concomitant CTO of the non-infarct-related coronary artery (non-IRA). Nevertheless, the prognostic impact of percutaneous coronary intervention (PCI) of CTO in the acute setting during AMI is still controversial. Due to the complexity of the CTO lesion, CTO-PCI leads to an increased risk of complications compared to non-occlusive coronary lesions. Therefore, this review outlines the prognostic impact of CTO-PCI in patients with AMI. In addition, the prognostic impact of periprocedural myocardial infarction caused by CTO-PCI will be discussed.

Latest developments in chronic total occlusion percutaneous coronary intervention

INTRODUCTION

Chronic Total Occlusion Percutaneous Coronary Intervention (CTO PCI) is now performed with high success rates and acceptable complication rates.

AREAS COVERED

We describe recent clinical and technological developments in CTO PCI from 2018 to 2020.

EXPERT OPINION

After publication of six randomized controlled trials, improving patient symptoms remains the principal indication for CTO PCI. Although good outcomes can be achieved with CTO PCI at experienced centers, success rates are significantly lower at less experienced centers, despite increased use in CTO crossing algorithms and development of novel and improved equipment and techniques.

Atrial Fibrillation Is Associated with Increased Mortality in Patients Presenting with Ventricular Tachyarrhythmias

Heterogenous data about the prognostic impact of atrial fibrillation (AF) in patients with ventricular tachyarrhythmias exist. Therefore, this study evaluates this impact of AF in patients presenting with ventricular tachyarrhythmias. 1,993 consecutive patients presenting with ventricular tachyarrhythmias (i.e. ventricular tachycardia and fibrillation (VT, VF)) on admission at one institution were included (from 2002 until 2016). All medical data of index and follow-up hospitalizations were collected during the complete follow-up period for each patient. Statistics comprised univariable Kaplan-Meier and multivariable Cox regression analyses in the unmatched consecutive cohort and after propensity-score matching for harmonization. The primary prognostic endpoint was long-term all-cause mortality at 2.5 years. AF was present in 31% of patients presenting with index ventricular tachyarrhythmias on admission (70% paroxysmal, 9% persistent, 21% permanent). VT was more common (67% versus 59%; p = 0.001) than VF (33% versus 41%; p = 0.001) in AF compared to non-AF patients. Long-term all-cause mortality at 2.5 years occurred more often in AF compared to non-AF patients (mortality rates 40% versus 24%, log rank p = 0.001; HR = 1.825; 95% CI 1.548-2.153; p = 0.001), which may be attributed to higher rates of all-cause mortality at 30 days, in-hospital mortality and mortality after discharge (p < 0.05) (secondary endpoints). Mortality differences were observed irrespective of index ventricular tachyarrhythmia (VT or VF), LV dysfunction or presence of an ICD. In conclusion, this study identifies AF as an independent predictor of death in patients presenting consecutively with ventricular tachyarrhythmias.