Comparison of Clinical Outcomes in Patients Undergoing Coronary Intervention with Drug-Eluting Stents or Bare-Metal Stents: A Nationwide Population Study

Diabetes and restenosis

Restenosis, defined as the re-narrowing of an arterial lumen after revascularization, represents an increasingly important issue in clinical practice. Indeed, as the number of stent placements has risen to an estimate that exceeds 3 million annually worldwide, revascularization procedures have become much more common. Several investigators have demonstrated that vessels in patients with diabetes mellitus have an increased risk restenosis. Here we present a systematic overview of the effects of diabetes on in-stent restenosis. Current classification and updated epidemiology of restenosis are discussed, alongside the main mechanisms underlying the pathophysiology of this event. Then, we summarize the clinical presentation of restenosis, emphasizing the importance of glycemic control in diabetic patients. Indeed, in diabetic patients who underwent revascularization procedures a proper glycemic control remains imperative.

Long term safety and efficacy of the Yukon Choice Flex sirolimus-eluting coronary stent-a real-world data from India

In-stent restenosis and stent thrombosis are the major concerns while choosing a coronary stent. This single-centre, retrospective study evaluated the one and three-year clinical outcomes following implantation of Yukon Choice Flex (YCF) sirolimus-eluting stent. A total of 168 consecutive patients with 217 lesions underwent stenting with YCF stent. The presentation was with acute coronary syndrome in 158 (94%) patients. At 3 years, 9 (5.3%) patients died due to cardiac cause. Myocardial infarction, and definite stent thrombosis occurred in 10 (6%) and 4 (2.4%) patients respectively. Redo stenting and coronary artery bypass surgery was performed in 3 (1.8%) and 1 (0.6%) patient respectively. The use of YCF sirolimus eluting stent was associated with a favourable safety and efficacy profile at one and three-years of follow-up in a high-risk population.

Association between phosphate and long-term outcome in CAD patients underwent coronary intervention

Phosphate has been linked to higher cardiovascular (CV) risk. However, whether phosphate is associated with poor outcomes for patients with coronary artery disease (CAD) after percutaneous coronary interventions (PCIs) remained undetermined. 2,894 CAD patients (2,220 male, aged 71.6 ± 12.2), who received PCI at TVGH from 2006 to 2015, with phosphate measurement, were enrolled. The primary outcome was the composite of major adverse CV events [MACE, comprising of CV death, nonfatal MI, and nonfatal stroke] and heart failure hospitalization (HHF). The key secondary outcome was MACE. There was a J-curve association between phosphate and CV events after adjusted for comorbidities and renal function. Phosphate around 3.2 ± 0.1 mg/dL was associated with the lowest CV risk. In Cox analysis, each 1 mg/dL increases in phosphate was associated with a higher risk of MACE + HHF (HR: 1.12, 95% CI: 1.05–1.21): CV death (HR: 1.37, 95% CI: 1.22–1.55) and HHF (HR: 1.12, 95% CI: 1.02–1.23). Subgroup analyses showed more prominent association between phosphate and MACE + HHF in male, age > 65, bare-metal stents (BMSs), LVEF < 50%, eGFR < 60, LDL > 70 mg/dL, and emergent PCI. Phosphate has a significant association with the risk of CV events in CAD patients undergoing PCI that was independent of comorbidities and renal function.

2020 Asian Pacific Society of Cardiology Consensus Recommendations on Antithrombotic Management for High-risk Chronic Coronary Syndrome

The unique characteristics of patients with chronic coronary syndrome (CCS) in the Asia-Pacific region, heterogeneous approaches because of differences in accesses and resources and low number of patients from the Asia-Pacific region in pivotal studies, mean that international guidelines cannot be routinely applied to these populations. The Asian Pacific Society of Cardiology developed these consensus recommendations to summarise current evidence on the management of CCS and provide recommendations to assist clinicians treat patients from the region. The consensus recommendations were developed by an expert consensus panel who reviewed and appraised the available literature, with focus on data from patients in Asia-Pacific. Consensus statements were developed then put to an online vote. The resulting recommendations provide guidance on the assessment and management of bleeding and ischaemic risks in Asian CCS patients. Furthermore, the selection of long-term antithrombotic therapy is discussed, including the role of single antiplatelet therapy, dual antiplatelet therapy and dual pathway inhibition therapy.

Chronic Femoropopliteal Occlusions: Comparison of Drug-Eluting Balloon Angioplasty with or without Prior Rotational Thrombectomy

BACKGROUND

The aim of this study was to compare drug eluting balloon (DEB) angioplasty with and without mechanical thrombectomy system in patients with chronic (> 6 months) femoropopliteal occlusions.

METHODS

We retrospectively identified patients from May 2012 to September 2014 at our clinic with severely diseased femoropopliteal arteries treated by endovascular approach with or without adjunctive thrombectomy system. All patients had ankle-brachial index (ABI) measured before and after the intervention, and regular clinical follow-up with Doppler ultrasonography performed at 1 month, 6 months and 1 year. Patients underwent peripheral angiography if needed.

RESULTS

Mechanical thrombectomy system (MTS + DEB) was used in 33 patients (31 enrolled 2 patients were lost to follow-up, mean lesion length 149.7mm ± 82.69). The remaining 33 patients were treated without MTS (31 enrolled 2 patients were lost to follow-up DEB N = 31 mean lesion length 157.3 mm ± 92.90). There were 5 restenosis in the MTS + DEB group (83.3% patency rate) and 5 restenosis in the DEB group (82.8% patency rate) at 1 year. The technical success rate was 93.5% in both groups. A statistically significant increase in the ABI (MTS + DEB before 0.47 ± 0.11 vs. after 0.92 ± 0.11 p < 0.01 DEB before 0.47 ± 0.11 vs. after 0.90 ± 0.14 p < 0.01) and improvement in Rutherford staging (p < 0.01) was noted in both groups following intervention.

CONCLUSIONS

DEB angioplasty is effective in the treatment of chronic total femoropopliteal occlusions. Combining DEB angioplasty and thrombectomy system does not appear to improve outcomes for treatment of chronic femoropopliteal occlusions.

Clinical Impact of High-Sensitivity Cardiac Troponin T on the Chronic Phase of Stable Angina after a Successful Initial Percutaneous Coronary Intervention

BACKGROUND

The purpose of this study was to investigate the clinical significance of elevated plasma high-sensitivity troponin T (hs-TnT) in the chronic phase in patients with stable angina pectoris (SAP) who underwent a successful percutaneous coronary intervention (PCI).

METHODS

This study enrolled 158 consecutive SAP patients who underwent routine follow-up coronary angiography 9 months after a successful PCI with the implantation of a second-generation drug-eluting stent. Patients with previous coronary artery bypass graft and renal dysfunction were excluded. Patients were divided into two groups according to hs-TnT plasma level at follow-up: elevated hs-TnT (≥ 0.015 ng/ml) group and non-elevated hs-TnT group.

RESULTS

Among the 158 subjects, 42 had an elevated hs-TnT level at follow-up. The elevated hs-TnT group had a significantly higher rate of any coronary lesion (in-stent restenosis and de novo lesions) in follow-up CAG (coronary angiography) than the non-elevated group (28.6% vs. 10.3%, p < 0.05). Multivariate analysis also showed that hs-TnT elevation was independently associated with the presence of significant coronary stenosis in the chronic phase (odds ratio: 3.99, 95% confidence interval: 1.38 to 11.53). The best cut-off value of the hs-TnT level at 9 months after a successful PCI to predict the presence of significant coronary stenosis was 0.016 ng/ml (sensitivity: 50.0%; specificity: 82.1%; area under the receiver operating characteristic curve: 0.67).

CONCLUSIONS

hs-TnT elevation was independently associated with the presence of coronary stenosis in the chronic phase in SAP patients with successful PCI. Routine measurement of hs-TnT in the chronic phase may be useful to refine the risk of patients after PCI.

Comparative Effectiveness and Safety of Antithrombotic Therapy in Atrial Fibrillation Patients Presenting with Acute Coronary Syndrome or Percutaneous Coronary Intervention

BACKGROUND

There remains insufficient evidence to determine the optimal antithrombotic strategy in atrial fibrillation (AF) patients presenting with acute coronary syndrome (ACS) or percutaneous coronary interventions (PCIs), especially in Asian populations.

OBJECTIVES

This study aimed to examine the real-world patterns of antithrombotic treatment among these patients and to compare the effectiveness and safety of different antithrombotic regimens.

METHODS

A retrospective cohort study was conducted in AF patients presenting with a new ACS or PCI during 2006/1/1-2016/4/1. Three antithrombotic regimens were compared: dual antiplatelet therapy (DAPT, as the reference group), triple therapy (TT: DAPT plus an oral anticoagulant), and dual therapy (DT: single antiplatelet plus an oral anticoagulant). The outcomes of interest were major adverse cardiac and cerebrovascular events (MACCEs) and bleeding. Treatment effect was estimated using a Cox proportional hazards model. Inverse probability of treatment weighting was used to balance baseline characteristics among comparison groups.

RESULTS

Overall, 532 patients were included. At discharge from the index hospitalization, DAPT was the most common antithrombotic therapy, followed by TT and DT. No significant difference in MACCEs was found among the different antithrombotic regimens. However, DT was associated with a lower risk of any bleeding [adjusted hazard ratio 0.20 (95% confidence interval, 0.06-0.75)] than DAPT.

CONCLUSIONS

In the study population, DAPT was the most commonly prescribed antithrombotic regimen for cardio-cerebrovascular disease prevention. The effectiveness outcomes were comparable across different antithrombotic strategies. The lower risk of bleeding with DT compared with DAPT warrants further investigation.

Early Phase II Comprehensive Cardiac Rehabilitation after Acute Myocardial Infarction

Background

Cardiac rehabilitation is beneficial for patients after ST-segment elevation myocardial infarction (STEMI). However, most institutes perform outpatient training phase (phase II) of post-MI cardiac rehabilitation after 2-4 weeks. To evaluate the possibility of performing cardiac rehabilitation with an earlier schedule after STEMI.

Methods

We conducted a series of early phase II cardiac rehabilitation starting from 5-7 days after STEMI, including the training group (n = 28) and the control group (n = 42).

Results

The results showed an improved mental component summary of the SF-36 questionnaire after 6 months in the training group. No adverse event was noticed during this early phase II training.

Conclusions

Cardiac rehabilitation after STEMI might be started earlier than previously thought for clinical use or further research.

The Utilization of Stress Tests Prior to Percutaneous Coronary Intervention for Stable Coronary Artery Disease in Taiwan

Background

Ischemia shown in non-invasive tests is considered to be a fundamental requirement for treating patients with stable coronary artery disease (CAD) with a percutaneous coronary intervention (PCI). In a nationwide cohort, we investigated the utilization of stress tests, including myocardial perfusion imaging (MPI), treadmill exercise test (TET) and stress echocardiography (SE) prior to elective PCI.

Methods

This retrospective study used the Longitudinal Health Insurance Database 2000 (LHID2000) of the National Health Insurance program in Taiwan. The LHID2000 is comprised of one million randomly sampled beneficiaries. We enrolled patients receiving elective PCI for stable CAD from 2000 to 2013. Stress tests performed within 90 days prior to PCI and patient characteristics correlated with the utilization of stress tests were investigated.

Results

During the investigation period, 3,163 patients received elective PCI for stable CAD and 1,847 (58.4%) patients had at least one stress test within 90 days prior to PCI. Among them, 1,461 (79.1%) had MPI, 1,228 had TET (66.4%) and only 1 had SE (0.05%). Age < 80 years, regional hospital and hyperlipidemia were independently associated with an increased likelihood of receiving stress tests. On the other hand, Charlson-comorbidity index score ≥ 1, prior catheterization and heart failure were independently associated with a decreased likelihood of receiving stress tests.

Conclusions

In the setting of stable CAD, almost 60% of our patients received stress tests within 90 days prior to elective PCI, and MPI was the most commonly used test.

Real-World Comparison of Drug-Eluting and Bare-Metal Stents in Superficial Femoral Artery Occlusive Disease with Trans-Atlantic Intersociety Consensus B Lesions: A 2-Year, Single-Institute Study

Background

Endovascular stenting has surpassed bypass surgery to become the first-line treatment for superficial femoral artery (SFA) occlusive disease, and various types of stents including bare-metal stents (BMSs), covered stents, and drug-eluting stents (DESs), have been approved for treatment. This retrospective, single-institute study compared the short-term, real-world outcomes of BMSs and DESs for treating SFA occlusive disease.

Methods

A retrospective chart review was used to enroll 94 patients who received a DES (n = 24) or BMS (n = 70) between 2009 and 2014. All patients had SFA occlusive disease with critical limb ischemia and an intermediate length of SFA occlusion [Trans-Atlantic Intersociety Consensus (TASC)-II B lesions] and were regularly followed for 2 years. All patient characteristics, procedural details, and outcomes were recorded.

Results

The 1-year primary patency rates in the BMS and DES groups were 71.4% and 87.5% (p = 0.169), respectively, and the corresponding 2-year rates were 61.4% and 79.2% (p = 0.139). The target lesion revascularization rate was 38.6% versus 20.8% (p = 0.139), the in-stent restenosis rate was 22.9% versus 0% (p = 0.009), the major limb amputation rate was 4.3% versus 0% (p = 0.568), the peripheral arterial disease-related mortality rate was 8.6% versus 0% (p = 0.332), and the all-cause mortality rate was 11.4% versus 0% (p = 0.109), respectively.

Conclusions

The 2-year results revealed higher safety, superior efficacy, and greater clinical benefits of DESs than BMSs for treating TASC-II B SFA occlusive disease. However, more cases and long-term follow-up are warranted.

Increased Risk of Venous Thromboembolism in Women with Uterine Leiomyoma: A Nationwide, Population-Based Case-Control Study

Background

Venous thromboembolism (VTE) is a sex-specific disease that has different presentations between men and women. Women with uterine leiomyoma can present with VTE without exhibiting the traditional risk factors. We investigated the relationship between a history of uterine leiomyoma and the risk of VTE using the National Health Insurance Research Database (NHIRD).

Methods

We conducted a retrospective, nationwide, population-based case-control study using the NHIRD. We identified 2,282 patients with diagnosed VTE and 392,635 subjects without VTE from 2000 to 2013. After development of an age and index diagnosis year frequency-matched model and propensity score-matched model, 2 models with a case-to-control ratio of 1 to 4 were established. Using the diagnosis of uterine leiomyoma as the exposure factor, conditional logistic regression was performed to examine the association between uterine leiomyoma and VTE. Multiple logistic regression analysis was used to investigate the joint effect of uterine leiomyoma and comorbid diseases on the risk of VTE.

Results

A strong association was observed between uterine leiomyoma and VTE in the overall patient model, frequency-matched model and propensity score-matched model [p < 0.0001, odds ratio (OR): 1.547; p = 0.0005, OR: 1.486; p = 0.0405, OR: 1.26, respectively]. In the subgroup analyses, women with uterine leiomyoma who were ≥ 45 years old were less likely to experience VTE, but women with uterine leiomyoma and anemia, cancer, coronary artery disease or heart failure were more likely to experience VTE.

Conclusions

Women with uterine leiomyomas have an increased risk of developing VTE, especially during reproductive periods or in the presence of specific diseases.