1
|
Povsic TJ, Korjian S, Bahit MC, Chi G, Duffy D, Alexander JH, Vinereanu D, Tricoci P, Mears SJ, Deckelbaum LI, Bonaca M, Ridker PM, Goodman SG, Cornel JH, Lewis BS, Parkhomenko A, Lopes RD, Aylward P, Lincoff AM, Heise M, Sacks F, Nicolau JC, Merkely B, Trebacz J, Libby P, Nicholls SJ, Pocock S, Bhatt DL, Kastelein J, Bode C, Mahaffey KW, Steg PG, Tendera M, Bainey KR, Harrington RA, Mehran R, Duerschmied D, Kingwell BA, Gibson CM. Effect of Reconstituted Human Apolipoprotein A-I on Recurrent Ischemic Events in Survivors of Acute MI. J Am Coll Cardiol 2024:S0735-1097(24)06702-0. [PMID: 38588930 DOI: 10.1016/j.jacc.2024.03.396] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2024] [Revised: 03/20/2024] [Accepted: 03/20/2024] [Indexed: 04/10/2024]
Abstract
BACKGROUND The AEGIS-II trial hypothesized that CSL112, an intravenous formulation of human apoA-I, would lower the risk of plaque disruption, decreasing the risk of recurrent events such as myocardial infarction (MI) among high-risk patients with MI. OBJECTIVES This exploratory analysis evaluates the effect of CSL112 therapy on the incidence of cardiovascular (CV) death and recurrent MI. METHODS The AEGIS-II trial was an international, multicenter, randomized, double-blind, placebo-controlled trial that randomized 18,219 high-risk acute MI patients to 4 weekly infusions of apoA-I (6 g CSL112) or placebo. RESULTS The incidence of the composite of CV death and type 1 MI was 11% to 16% lower in the CSL112 group over the study period (HR: 0.84; 95% CI: 0.7-1.0; P = 0.056 at day 90; HR: 0.86; 95% CI: 0.74-0.99; P = 0.048 at day 180; and HR: 0.89; 95% CI: 0.79-1.01; P = 0.07 at day 365). Similarly, the incidence of CV death or any MI was numerically lower in CSL112-treated patients throughout the follow-up period (HR: 0.92; 95% CI: 0.80-1.05 at day 90, HR: 0.89; 95% CI: 0.79-0.996 at day 180, HR: 0.91; 95% CI: 0.83-1.01 at day 365). The effect of CSL112 treatment on MI was predominantly observed for type 1 MI and type 4b (MI due to stent thrombosis). CONCLUSIONS Although CSL112 did not significantly reduce the occurrence of the primary study endpoints, patients treated with CSL112 infusions had numerically lower rates of CV death and MI, type-1 MI, and stent thrombosis-related MI compared with placebo. These findings could suggest a role of apoA-I in reducing subsequent plaque disruption events via enhanced cholesterol efflux. Further prospective data would be needed to confirm these observations.
Collapse
Affiliation(s)
- Thomas J Povsic
- Duke Clinical Research Institute/Duke University Medical Center, Durham, North Carolina, USA
| | - Serge Korjian
- PERFUSE Study Group, Division of Cardiovascular Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | | | - Gerald Chi
- PERFUSE Study Group, Division of Cardiovascular Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | | | - John H Alexander
- Duke Clinical Research Institute/Duke University Medical Center, Durham, North Carolina, USA
| | - Dragos Vinereanu
- University of Medicine and Pharmacy Carol Davila, University and Emergency Hospital, Bucharest, Romania
| | | | | | | | - Marc Bonaca
- University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, Colorado, USA
| | - Paul M Ridker
- Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Shaun G Goodman
- Canadian VIGOUR Centre, University of Alberta, Edmonton, Alberta, Canada
| | - Jan H Cornel
- Radboud University Medical Center, Nijmegen and Noordwest Ziekenhuisgroep, Alkmaar, the Netherlands
| | - Basil S Lewis
- Lady Davis Carmel Medical Center and the Technion-Israel Institute of Technology, Aurora, Colorado, USA
| | | | - Renato D Lopes
- Duke Clinical Research Institute/Duke University Medical Center, Durham, North Carolina, USA
| | - Philip Aylward
- South Australian Health and Medical Research Institute/SAHMRI, Adelaide, South Australia, Australia
| | - A Michael Lincoff
- Cleveland Clinic Coordinating Center for Clinical Research, Cleveland, Ohio, USA
| | - Mark Heise
- CSL Behring, King of Prussia, Pennsylvania, USA
| | - Frank Sacks
- Department of Nutrition, Harvard School of Public Health, Harvard Medical School, Boston, Massachusetts, USA
| | - Jose C Nicolau
- Instituto do Coracao (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - Bela Merkely
- Heart and Vascular Center of Semmelweis University, Budapest, Hungary
| | - Jaroslaw Trebacz
- Krakowski Szpital Specjalistyczny im. Jana Pawła II, Kraków, Poland
| | - Peter Libby
- Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Stephen J Nicholls
- Victorian Heart Hospital, Monash Heart and Intensive Care, Clayton, Victoria, Australia
| | - Stuart Pocock
- London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Deepak L Bhatt
- Mount Sinai Fuster Heart Hospital, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - John Kastelein
- Academic Medical Centre/University of Amsterdam, Amsterdam, the Netherlands
| | | | - Kenneth W Mahaffey
- Stanford Center for Clinical Research, Stanford University School of Medicine, Stanford, California, USA
| | - P Gabriel Steg
- Universite Paris-Cité, INSERM 1148, FACT, and AP-HP, Hôpital Bichat, Paris, France
| | - Michal Tendera
- Department of Cardiology and Structural Heart Disease, School of Medicine in Katowice, Medical University of Silesia, Katowice, Poland
| | - Kevin R Bainey
- Canadian VIGOUR Centre, University of Alberta, Edmonton, Alberta, Canada
| | | | | | - Daniel Duerschmied
- Cardiology, Angiology, Haemostaseology, and Medical Intensive Care, Medical Centre Mannheim, Medical Faculty Mannheim, Heidelberg University, Heidelberg, Germany
| | | | - C Michael Gibson
- PERFUSE Study Group, Division of Cardiovascular Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA.
| |
Collapse
|
2
|
Welsh RC, Gouda P, Dover D, Bainey KR, McAlister FA, Kaul P. Applicability and impact of the COMPASS trial in a Canadian population of patients with atherosclerotic disease. Atherosclerosis 2024:117486. [PMID: 38582637 DOI: 10.1016/j.atherosclerosis.2024.117486] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Revised: 02/18/2024] [Accepted: 02/22/2024] [Indexed: 04/08/2024]
Abstract
BACKGROUND AND AIMS In the COMPASS trial, low-dose rivaroxaban with aspirin improved cardiovascular outcomes in patients with atherosclerotic cardiovascular disease (ASCVD). We aimed to assess the potential clinical implications of this therapy in a generalizable population. METHODS AND RESULTS A retrospective cohort of adults with ASVCD was formed using healthcare administrative databases in Alberta, Canada (population 4.4 million). Patients with a new diagnosis between 2008 and 2019 formed the epidemiological cohort (n = 224,600) and those with long-term follow-up (>5 years) formed the outcomes cohort (n = 232,460). The primary outcome of major adverse cardiovascular events (MACE) was assessed and categorized based on the COMPASS trial eligibility. In the outcomes cohort, 77% had only coronary artery disease, 15% had only peripheral artery disease, and 8% had both. Of those, 37% met the COMPASS trial eligibility criteria, 36% met exclusion criteria and 27% did not meet inclusion criteria. Over a median of 7.8 years, the COMPASS exclusion group demonstrated the highest rate of MACE (5.9 per 100 person-years), following by the eligible group and the group that did not meet COMPASS inclusion criteria (3.1 and 1.4 per 100 person-years respectively). The expected net clinical benefit of antithrombotic therapy in the eligible group was 5.6 fewer events per 1000 person-years. CONCLUSIONS In a real-world population of 4.4 million adults, there are roughly 20,000 new cases of ASVCD diagnosed yearly, with ∼40% being eligible for the addition of low-dose rivaroxaban therapy to antiplatelet therapy. The theoretical implementation of dual antithrombotic treatment in this population could result in a substantial reduction in cardiovascular morbidity and mortality.
Collapse
Affiliation(s)
- Robert C Welsh
- Division of Cardiology, University of Alberta and Mazankowski Alberta Heart Institute, Edmonton, Alberta, Canada; Canadian VIGOUR Centre, Edmonton, Alberta, Canada.
| | - Pishoy Gouda
- Division of Cardiology, University of Alberta and Mazankowski Alberta Heart Institute, Edmonton, Alberta, Canada
| | - Doug Dover
- Division of Cardiology, University of Alberta and Mazankowski Alberta Heart Institute, Edmonton, Alberta, Canada; Canadian VIGOUR Centre, Edmonton, Alberta, Canada
| | - Kevin R Bainey
- Division of Cardiology, University of Alberta and Mazankowski Alberta Heart Institute, Edmonton, Alberta, Canada; Canadian VIGOUR Centre, Edmonton, Alberta, Canada
| | - Finlay A McAlister
- Division of Cardiology, University of Alberta and Mazankowski Alberta Heart Institute, Edmonton, Alberta, Canada; Canadian VIGOUR Centre, Edmonton, Alberta, Canada
| | - Padma Kaul
- Division of Cardiology, University of Alberta and Mazankowski Alberta Heart Institute, Edmonton, Alberta, Canada; Canadian VIGOUR Centre, Edmonton, Alberta, Canada
| |
Collapse
|
3
|
Gouda P, Islam S, Dover DC, Kaul P, Bainey KR, Welsh RC. Outcomes of management strategies in patients with prior coronary artery bypass grafting presenting with an acute coronary syndrome. Atherosclerosis 2024; 393:117477. [PMID: 38643672 DOI: 10.1016/j.atherosclerosis.2024.117477] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2023] [Revised: 02/02/2024] [Accepted: 02/02/2024] [Indexed: 04/23/2024]
Abstract
BACKGROUND Patients with prior coronary artery bypass grafting (CABG) presenting with an acute coronary syndrome (ACS) have poor outcomes and the optimal treatment strategy for this population is unknown. METHODS Using linked administrative databases, we examined patients with an ACS between 2008 and 2019, identifying patients with prior CABG. Patients were categorized by ACS presentation type and treatment strategy. Our primary outcome was the composite of death and recurrent myocardial infarction at one year. RESULTS Of 54,641 patients who presented with an ACS, 1670 (3.1%) had a history of prior CABG. Of those, 11.0% presented with an ST-elevation myocardial infarction (STEMI) of which, 15.3% were treated medically, 31.1% underwent angiography but were treated medically, 22.4% with fibrinolytic therapy and 31.1% with primary PCI. The primary outcome rate was the highest (36.8%) in patients who did not undergo angiography and was similar in the primary PCI (20.8%) and fibrinolytic group (21.9%). In patients presenting with a non-ST elevation acute coronary syndrome (NSTE-ACS) (89.0%), 33.2% were treated medically, 38.5% underwent angiography but were treated medically and 28.2% were treated with PCI. Compared to those who underwent PCI, patients treated conservatively demonstrated a higher risk of the composite outcome (14.8% vs 27.3%; adjusted hazard ratio 1.70, 95% confidence interval 1.22-2.37). CONCLUSIONS Patients with prior CABG presenting with an ACS are often treated conservatively without PCI, which is associated with a higher risk of adverse events.
Collapse
Affiliation(s)
- Pishoy Gouda
- Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Alberta, Canada
| | - Sunjidatul Islam
- Canadian VIGOUR Centre, University of Alberta, Edmonton, Alberta, Canada
| | - Douglas C Dover
- Canadian VIGOUR Centre, University of Alberta, Edmonton, Alberta, Canada
| | - Padma Kaul
- Canadian VIGOUR Centre, University of Alberta, Edmonton, Alberta, Canada
| | - Kevin R Bainey
- Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Alberta, Canada; Canadian VIGOUR Centre, University of Alberta, Edmonton, Alberta, Canada
| | - Robert C Welsh
- Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Alberta, Canada; Canadian VIGOUR Centre, University of Alberta, Edmonton, Alberta, Canada.
| |
Collapse
|
4
|
Bainey KR, Marquis-Gravel G, Belley-Côté E, Turgeon RD, Ackman ML, Babadagli HE, Bewick D, Boivin-Proulx LA, Cantor WJ, Fremes SE, Graham MM, Lordkipanidzé M, Madan M, Mansour S, Mehta SR, Potter BJ, Shavadia J, So DF, Tanguay JF, Welsh RC, Yan AT, Bagai A, Bagur R, Bucci C, Elbarouni B, Geller C, Lavoie A, Lawler P, Liu S, Mancini J, Wong GC. Canadian Cardiovascular Society/Canadian Association of Interventional Cardiology 2023 Focused Update of the Guidelines for the Use of Antiplatelet Therapy. Can J Cardiol 2024; 40:160-181. [PMID: 38104631 DOI: 10.1016/j.cjca.2023.10.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2023] [Revised: 10/02/2023] [Accepted: 10/03/2023] [Indexed: 12/19/2023] Open
Abstract
Antiplatelet therapy (APT) is the foundation of treatment and prevention of atherothrombotic events in patients with atherosclerotic cardiovascular disease. Selecting the optimal APT strategies to reduce major adverse cardiovascular events, while balancing bleeding risk, requires ongoing review of clinical trials. Appended, the focused update of the Canadian Cardiovascular Society/Canadian Association of Interventional Cardiology guidelines for the use of APT provides recommendations on the following topics: (1) use of acetylsalicylic acid in primary prevention of atherosclerotic cardiovascular disease; (2) dual APT (DAPT) duration after percutaneous coronary intervention (PCI) in patients at high bleeding risk; (3) potent DAPT (P2Y12 inhibitor) choice in patients who present with an acute coronary syndrome (ACS) and possible DAPT de-escalation strategies after PCI; (4) choice and duration of DAPT in ACS patients who are medically treated without revascularization; (5) pretreatment with DAPT (P2Y12 inhibitor) before elective or nonelective coronary angiography; (6) perioperative and longer-term APT management in patients who require coronary artery bypass grafting surgery; and (7) use of APT in patients with atrial fibrillation who require oral anticoagulation after PCI or medically managed ACS. These recommendations are all on the basis of systematic reviews and meta-analyses conducted as part of the development of these guidelines, provided in the Supplementary Material.
Collapse
Affiliation(s)
- Kevin R Bainey
- Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Alberta, Canada.
| | | | - Emilie Belley-Côté
- Population Health Research Institute, McMaster University, Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - Ricky D Turgeon
- University of British Columbia, St Paul's Hospital PHARM-HF Clinic, Vancouver, British Columbia, Canada
| | | | - Hazal E Babadagli
- Pharmacy Services, Alberta Health Services, Mazankowski Alberta Heart Institute, Edmonton, Alberta, Canada
| | - David Bewick
- Division of Cardiology, Department of Medicine, Dalhousie University, Saint John Regional Hospital, Saint John, New Brunswick, Canada
| | | | - Warren J Cantor
- Southlake Regional Health Centre, University of Toronto, Toronto, Ontario, Canada
| | - Stephen E Fremes
- University of Toronto, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Michelle M Graham
- Division of Cardiology, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Marie Lordkipanidzé
- Faculté de pharmacie, Université de Montréal, Research Center, Montréal Heart Institute, Montréal, Québec, Canada
| | - Mina Madan
- Schulich Heart Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Samer Mansour
- Centre Hospitalier de l'Université de Montréal, Montréal, Québec, Canada
| | - Shamir R Mehta
- Population Health Research Institute, McMaster University, Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - Brian J Potter
- Centre Hospitalier de l'Université de Montréal, Montréal, Québec, Canada
| | - Jay Shavadia
- College of Medicine, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Derek F So
- University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Jean-François Tanguay
- Institut de Cardiologie de Montréal, Université de Montréal, Montréal, Québec, Canada
| | - Robert C Welsh
- Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Alberta, Canada
| | - Andrew T Yan
- Division of Cardiology, Unity Health Toronto, St Michael's Hospital, Toronto, Ontario, Canada
| | - Akshay Bagai
- Terrence Donnelly Heart Centre, St Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Rodrigo Bagur
- London Health Sciences Centre, Western University, London, Ontario, Canada
| | - Claudia Bucci
- Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Basem Elbarouni
- Department of Medicine, St Boniface Hospital, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Carol Geller
- University of Ottawa, Centretown Community Health Centre, Ottawa, Ontario, Canada
| | - Andrea Lavoie
- Prairie Vascular Research Inc, Regina, Saskatchewan, Canada
| | - Patrick Lawler
- Peter Munk Cardiac Centre, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Shuangbo Liu
- Department of Medicine, St Boniface Hospital, University of Manitoba, Winnipeg, Manitoba, Canada
| | - John Mancini
- Division of Cardiology, Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Graham C Wong
- Division of Cardiology, Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| |
Collapse
|
5
|
van Diepen S, Zheng Y, Senaratne JM, Tyrrell BD, Das D, Thiele H, Henry TD, Bainey KR, Welsh RC. Reperfusion in Patients With ST-Segment-Elevation Myocardial Infarction With Cardiogenic Shock and Prolonged Interhospital Transport Times. Circ Cardiovasc Interv 2024; 17:e013415. [PMID: 38293830 DOI: 10.1161/circinterventions.123.013415] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2023] [Accepted: 11/09/2023] [Indexed: 02/01/2024]
Abstract
BACKGROUND In patients with ST-segment-elevation myocardial infarction complicated by cardiogenic shock, primary percutaneous coronary intervention (pPCI) is the preferred revascularization option. Little is known about the efficacy and safety of a pharmacoinvasive approach for patients with cardiogenic shock presenting to a non-PCI hospital with prolonged interhospital transport times. METHODS In a retrospective analysis of geographically extensive ST-segment-elevation myocardial infarction network (2006-2021), 426 patients with cardiogenic shock and ST-segment-elevation myocardial infarction presented to a non-PCI-capable hospital and underwent reperfusion therapy (53.8% pharmacoinvasive and 46.2% pPCI). The primary clinical outcome was a composite of in-hospital mortality, renal failure requiring dialysis, cardiac arrest, or mechanical circulatory support, and the primary safety outcome was major bleeding defined as an intracranial hemorrhage or bleeding that required transfusion was compared in an inverse probability weighted model. The electrocardiographic reperfusion outcome of interest was the worst residual ST-segment-elevation. RESULTS Patients with pharmacoinvasive treatment had longer median interhospital transport (3 hours versus 1 hour) and shorter median symptom-onset-to-reperfusion (125 minute-to-needle versus 419 minute-to-balloon) times. ST-segment resolution ≥50% on the postfibrinolysis ECG was 56.6%. Postcatheterization, worst lead residual ST-segment-elevation <1 mm (57.3% versus 46.3%; P=0.01) was higher in the pharmacoinvasive compared with the pPCI cohort, but no differences were observed in the worst lead ST-segment-elevation resolution ≥50% (77.4% versus 81.8%; P=0.57). The primary clinical end point was lower in the pharmacoinvasive cohort (35.2% versus 57.0%; inverse probability weighted odds ratio, 0.44 [95% CI, 0.26-0.72]; P<0.01) compared with patients who received pPCI. An interaction between interhospital transfer time and reperfusion strategy with all-cause mortality was observed, favoring a pharmacoinvasive approach with transfer times >60 minutes. The incidence of the primary safety outcome was 10.1% in the pharmacoinvasive arm versus 18.7% in pPCI (adjusted odds ratio, 0.41 [95% CI, 0.14-1.09]; P=0.08). CONCLUSIONS In patients with ST-segment-elevation myocardial infarction presenting with cardiogenic shock and prolonged interhospital transport times, a pharmacoinvasive approach was associated with improved electrocardiographic reperfusion and a lower rate of death, dialysis, or mechanical circulatory support without an increase in major bleeding.
Collapse
Affiliation(s)
- Sean van Diepen
- Department of Critical Care (S.v.D., J.M.S.), University of Alberta, Edmonton, Canada
- Division of Cardiology, Department of Medicine (S.v.D., J.M.S., K.R.B., R.C.W.), University of Alberta, Edmonton, Canada
- Canadian VIGOUR Center (S.v.D., Y.Z., K.R.B., R.C.W.), University of Alberta, Edmonton, Canada
| | - Yinggan Zheng
- Canadian VIGOUR Center (S.v.D., Y.Z., K.R.B., R.C.W.), University of Alberta, Edmonton, Canada
| | - Janek M Senaratne
- Department of Critical Care (S.v.D., J.M.S.), University of Alberta, Edmonton, Canada
- Division of Cardiology, Department of Medicine (S.v.D., J.M.S., K.R.B., R.C.W.), University of Alberta, Edmonton, Canada
| | | | - Debraj Das
- CK Hui Heart Center, Edmonton, Alberta, Canada (B.D.T., D.D.)
| | - Holger Thiele
- Department of Internal Medicine/Cardiology, Heart Center Leipzig, University of Leipzig, Germany (H.T.)
| | - Timothy D Henry
- Carl and Edyth Lindner Research Center at the Christ Hospital, Cincinnati, OH (T.D.H.)
| | - Kevin R Bainey
- Division of Cardiology, Department of Medicine (S.v.D., J.M.S., K.R.B., R.C.W.), University of Alberta, Edmonton, Canada
- Canadian VIGOUR Center (S.v.D., Y.Z., K.R.B., R.C.W.), University of Alberta, Edmonton, Canada
| | - Robert C Welsh
- Division of Cardiology, Department of Medicine (S.v.D., J.M.S., K.R.B., R.C.W.), University of Alberta, Edmonton, Canada
- Canadian VIGOUR Center (S.v.D., Y.Z., K.R.B., R.C.W.), University of Alberta, Edmonton, Canada
| |
Collapse
|
6
|
Sunner SS, Welsh RC, Bainey KR. Prevalence of Peripheral Arterial Disease in Patients With Coronary Artery Disease After Cardiac Catheterization: A Prospective Observational Study. Am J Cardiol 2024; 211:251-254. [PMID: 37984639 DOI: 10.1016/j.amjcard.2023.11.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2023] [Revised: 10/30/2023] [Accepted: 11/11/2023] [Indexed: 11/22/2023]
Affiliation(s)
- Sanjot S Sunner
- Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Canada
| | - Robert C Welsh
- Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Canada; Canadian VIGOUR Centre, University of Alberta, Edmonton, Canada
| | - Kevin R Bainey
- Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Canada; Canadian VIGOUR Centre, University of Alberta, Edmonton, Canada.
| |
Collapse
|
7
|
Alkasab M, Bainey KR. Clopidogrel Monotherapy in Older Stable Ischemic Heart Disease Patients Receiving Percutaneous Coronary Intervention: A Paradigm Shift? Can J Cardiol 2024; 40:53-55. [PMID: 37924968 DOI: 10.1016/j.cjca.2023.10.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2023] [Revised: 10/30/2023] [Accepted: 10/31/2023] [Indexed: 11/06/2023] Open
Affiliation(s)
- Mohammed Alkasab
- Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Alberta, Canada
| | - Kevin R Bainey
- Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Alberta, Canada.
| |
Collapse
|
8
|
Bainey KR, Wood DA, Bossard M, Campo G, Cantor WJ, Lavi S, Madan M, Mehran R, Pinilla-Echeverri N, Rao S, Sarma J, Sheth T, Stankovic G, Steg PG, Storey RF, Tanguay JF, Velianou JL, Welsh RC, Mani T, Cairns JA, Mehta SR. Effects of complete revascularization according to age in patients with ST-segment elevation myocardial infarction and multivessel disease (COMPLETE-AGE). Am Heart J 2024; 267:70-80. [PMID: 37871781 DOI: 10.1016/j.ahj.2023.10.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Revised: 10/03/2023] [Accepted: 10/19/2023] [Indexed: 10/25/2023]
Abstract
BACKGROUND In ST-segment elevation myocardial infarction (STEMI), complete revascularization with percutaneous coronary intervention (PCI) reduces major cardiovascular events compared with culprit-lesion-only PCI. Whether age influences these results remains unknown. METHODS COMPLETE was a multinational, randomized trial evaluating a strategy of staged complete revascularization, consisting of angiography-guided PCI of all suitable nonculprit lesions, versus a strategy of culprit-lesion-only PCI. In this prespecified subgroup analysis, treatment effect according to age (≥65 years vs <65 years) was determined for the first coprimary outcome of cardiovascular (CV) death or new myocardial infarction (MI) and the second coprimary outcome of CV death, new MI, or ischemia-driven revascularization (IDR). Median follow-up was 35.8 months (interquartile range [IQR]: 27.6-44.3 months). RESULTS Of 4,041 patients randomized in COMPLETE, 1,613 were aged ≥ 65 years (39.9%). Higher event rates were observed for both coprimary outcomes in patients aged ≥ 65 years comparted with those aged < 65 years (11.2% vs 7.9%, HR 1.49, 95% CI 1.22-1.83; 14.4% vs 11.8%, HR 1.28, 95% CI 1.07-1.52, respectively). Complete revascularization reduced the first coprimary outcome in patients ≥ 65 years (9.7% vs 12.5%, HR 0.77; 95% CI, 0.58-1.04) and < 65 years (6.7% vs 9.1%, HR 0.72; 95% CI, 0.54-0.96)(interaction P = .74). The second coprimary outcome was reduced in those ≥ 65 years (HR 0.56, 95% CI, 0.43-0.74) and < 65 years (HR 0.48, 95% CI, 0.37-0.61 (interaction P = .37). A sensitivity analysis was performed with consistent results demonstrated using a 75-year threshold (albeit attenuated). CONCLUSIONS In patients with STEMI and multivessel CAD, complete revascularization compared with culprit-lesion-only PCI reduced major cardiovascular events regardless of patient age and could be considered as a revascularization strategy in older adults.
Collapse
Affiliation(s)
- Kevin R Bainey
- Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Alberta, Canada
| | - David A Wood
- University of British Columbia, Vancouver, British Columbia, Canada
| | | | - Gianluca Campo
- Azienda Ospedaliero Universitaria di Ferrara, University of Ferrara, Ferrara, Italy
| | - Warren J Cantor
- Southlake Regional Health Centre, University of Toronto, Toronto, Ontario, Canada
| | - Shahar Lavi
- Western University, London Health Sciences Centre, London, Ontario, Canada
| | - Mina Madan
- Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Roxana Mehran
- The Zena A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Natalia Pinilla-Echeverri
- Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - Sunil Rao
- NYU Langone Health System, New York, NY
| | - Jaydeep Sarma
- North West Heart Centre, Wythenshawe Hospital, Manchester, United Kingdom
| | - Tej Sheth
- Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - Goran Stankovic
- University Clinical Center of Serbia and Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | | | - Robert F Storey
- Department of Infection, Immunity, and Cardiovascular Disease, University of Sheffield, Sheffield, United Kingdom
| | | | - James L Velianou
- McMaster University and Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - Robert C Welsh
- Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Alberta, Canada
| | - Thenmozhi Mani
- Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - John A Cairns
- University of British Columbia, Vancouver, British Columbia, Canada
| | - Shamir R Mehta
- Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, Ontario, Canada.
| |
Collapse
|
9
|
Kumar A, Connelly K, Vora K, Bainey KR, Howarth A, Leipsic J, Betteridge-LeBlanc S, Prato FS, Leong-Poi H, Main A, Atoui R, Saw J, Larose E, Graham MM, Ruel M, Dharmakumar R. The Canadian Cardiovascular Society Classification of Acute Atherothrombotic Myocardial Infarction Based on Stages of Tissue Injury Severity: An Expert Consensus Statement. Can J Cardiol 2024; 40:1-14. [PMID: 37906238 DOI: 10.1016/j.cjca.2023.09.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2022] [Revised: 09/09/2023] [Accepted: 09/10/2023] [Indexed: 11/02/2023] Open
Abstract
Myocardial infarction (MI) remains a leading cause of morbidity and mortality. In atherothrombotic MI (ST-elevation MI and type 1 non-ST-elevation MI), coronary artery occlusion leads to ischemia. Subsequent cardiomyocyte necrosis evolves over time as a wavefront within the territory at risk. The spectrum of ischemia and reperfusion injury is wide: it can be minimal in aborted MI or myocardial necrosis can be large and complicated by microvascular obstruction and reperfusion hemorrhage. Established risk scores and infarct classifications help with patient management but do not consider tissue injury characteristics. This document outlines the Canadian Cardiovascular Society classification of acute MI. It is an expert consensus formed on the basis of decades of data on atherothrombotic MI with reperfusion therapy. Four stages of progressively worsening myocardial tissue injury are identified: (1) aborted MI (no/minimal myocardial necrosis); (2) MI with significant cardiomyocyte necrosis, but without microvascular injury; (3) cardiomyocyte necrosis and microvascular dysfunction leading to microvascular obstruction (ie, "no-reflow"); and (4) cardiomyocyte and microvascular necrosis leading to reperfusion hemorrhage. Each stage reflects progression of tissue pathology of myocardial ischemia and reperfusion injury from the previous stage. Clinical studies have shown worse remodeling and increase in adverse clinical outcomes with progressive injury. Notably, microvascular injury is of particular importance, with the most severe form (hemorrhagic MI) leading to infarct expansion and risk of mechanical complications. This classification has the potential to stratify risk in MI patients and lay the groundwork for development of new, injury stage-specific and tissue pathology-based therapies for MI.
Collapse
Affiliation(s)
- Andreas Kumar
- Northern Ontario School of Medicine University, and Department of Cardiovascular Sciences, Health Sciences North, Sudbury, Ontario, Canada; Health Sciences North, Sudbury, Ontario, Canada.
| | - Kim Connelly
- Keenan Research Centre for Biomedical Science, Unity Health Toronto, St Michael's Hospital, University of Toronto, and Department of Physiology, University of Toronto, Toronto, Ontario, Canada
| | - Keyur Vora
- Krannert Cardiovascular Research Center, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Kevin R Bainey
- University of Alberta, Faculty of Medicine and Dentistry, Mazankowski Alberta Heart Institute, Canadian VIGOUR Centre, Edmonton, Alberta, Canada
| | - Andrew Howarth
- Cardiac Sciences, Faculty of Medicine, University of Calgary, and Libin Cardiovascular Institute, Calgary, Alberta, Canada
| | - Jonathon Leipsic
- Departments of Radiology and Cardiology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Suzanne Betteridge-LeBlanc
- Health Sciences North, Sudbury, Ontario, Canada; Northern Ontario School of Medicine University, and Health Sciences North, Sudbury, Ontario, Canada
| | - Frank S Prato
- Lawson Research Institute, University of Western Ontario, London, Ontario, Canada
| | - Howard Leong-Poi
- The Division of Cardiology, St Michael's Hospital, Unity Health Toronto, University of Toronto, Toronto, Ontario, Canada
| | - Anthony Main
- Northern Ontario School of Medicine University, and Department of Cardiovascular Sciences, Health Sciences North, Sudbury, Ontario, Canada; Health Sciences North, Sudbury, Ontario, Canada
| | - Rony Atoui
- Northern Ontario School of Medicine University, and Department of Surgery, Health Sciences North, Sudbury, Ontario, Canada
| | - Jacqueline Saw
- Division of Cardiology, Vancouver General Hospital, University of British Columbia, Vancouver, British Columbia, Canada
| | - Eric Larose
- Department of Medicine, University of Laval, Quebec City, Quebec, Canada
| | - Michelle M Graham
- Division of Cardiology, University of Alberta, Faculty of Medicine and Dentistry, Mazankowski Alberta Heart Institute, Edmonton, Alberta, Canada
| | - Marc Ruel
- University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Rohan Dharmakumar
- Krannert Cardiovascular Research Center, Indiana University School of Medicine/IU Health Cardiovascular Institute, Indianapolis, Indiana, USA
| |
Collapse
|
10
|
Laferrière C, Moazzami C, Belley-Côté E, Bainey KR, Marquis-Gravel G, Fama A, Lordkipanidzé M, Potter BJ. Aspirin for the Primary Prevention of Vascular Ischemic Events: An Updated Systematic Review and Meta-analysis to Support Shared Decision-Making. CJC Open 2023; 5:881-890. [PMID: 38204851 PMCID: PMC10774080 DOI: 10.1016/j.cjco.2023.08.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2023] [Accepted: 08/25/2023] [Indexed: 01/12/2024] Open
Abstract
Background Since the publication of the 2010 Canadian antiplatelet guidelines, several large randomized controlled trials (RCTs) have evaluated the role of aspirin (ASA) use in primary prevention. We evaluated the effect of ASA use, compared with no ASA, on ischemic and bleeding events in patients without known atherosclerotic cardiovascular diseases. Methods We updated a published systematic review and meta-analysis by searching MEDLINE, Embase, and CENTRAL for the period up to March 2023. We included RCTs that enrolled patients for primary prevention of atherosclerotic cardiovascular diseases, and compared use of ASA to no ASA. We assessed risk of bias (RoB) using the Cochrane RoB tool, and certainty of evidence using the grading recommendations, assessment, development, and evaluation (GRADE) criteria. The primary efficacy outcome was major adverse cardiovascular events (MACE) (death, myocardial infarction, or stroke). The primary safety outcomes were intracranial hemorrhage and extracranial major bleeding events. We used a random-effects model to generate pooled risk ratios (RRs) and 95% confidence intervals (CIs). Results We included 14 RCTs (n = 167,587) at overall low RoB, with a median follow-up of 5 years. Compared to no ASA, ASA use reduced the incidence of MACE (RR 0.90, 95% CI 0.86-0.94), with a higher risk of intracranial hemorrhage (RR 1.33, 95% CI 1.13-1.56) and extracranial major bleeding (RR 1.67, 95% CI 1.36-2.06). In prespecified subgroups of age, sex, and diabetes, effect estimates were consistent. Conclusions ASA use in primary prevention is associated with a consistent reduction in MACE, but at the expense of major bleeding events. Patient values and preferences should be taken into account when considering ASA use for primary prevention.
Collapse
Affiliation(s)
- Chloë Laferrière
- Université de Montréal, Faculté de médecine, Montréal, Quebec, Canada
| | - Chloé Moazzami
- Université de Montréal, Faculté de médecine, Montréal, Quebec, Canada
| | - Emilie Belley-Côté
- Population Health Research Institute (PHRI), Hamilton, Ontario, Canada
- McMaster University, Hamilton, Ontario, Canada
| | - Kevin R. Bainey
- Faculty of Medicine. University of Alberta, Edmonton, Alberta, Canada
- Mazankowski Alberta Heart Institute, Edmonton, Alberta, Canada
| | - Guillaume Marquis-Gravel
- Université de Montréal, Faculté de médecine, Montréal, Quebec, Canada
- Centre de recherche de l’Institut de cardiologie de Montréal, Montréal, Quebec, Canada
| | - Alexa Fama
- Population Health Research Institute (PHRI), Hamilton, Ontario, Canada
| | - Marie Lordkipanidzé
- Université de Montréal, Faculté de médecine, Montréal, Quebec, Canada
- Faculté de pharmacie, Université de Montréal, Montréal, Quebec, Canada
| | - Brian J. Potter
- Université de Montréal, Faculté de médecine, Montréal, Quebec, Canada
- Centre de recherche du Centre hospitalier de l’Université de Montréal (CRCHUM), Montréal, Quebec, Canada
| |
Collapse
|
11
|
Hausvater A, Spruill TM, Xia Y, Smilowitz NR, Arabadjian M, Shah B, Park K, Giesler C, Marzo K, Thomas D, Wei J, Trost J, Mehta PK, Har B, Bainey KR, Zhong H, Hochman JS, Reynolds HR. Psychosocial Factors of Women Presenting With Myocardial Infarction With or Without Obstructive Coronary Arteries. J Am Coll Cardiol 2023; 82:1649-1658. [PMID: 37852694 PMCID: PMC11010594 DOI: 10.1016/j.jacc.2023.08.028] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Revised: 08/14/2023] [Accepted: 08/15/2023] [Indexed: 10/20/2023]
Abstract
BACKGROUND Women with myocardial infarction (MI) are more likely to have elevated stress levels and depression than men with MI. OBJECTIVES We investigated psychosocial factors in women with myocardial infarction with nonobstructive coronary arteries (MINOCA) and those with MI and obstructive coronary artery disease (CAD). METHODS Women with MI enrolled in a multicenter study and completed measures of perceived stress (Perceived Stress Scale-4) and depressive symptoms (Patient Health Questionnaire-2) at the time of MI (baseline) and 2 months later. Stress, depression, and changes over time were compared between MI subtypes. RESULTS We included 172 MINOCA and 314 MI-CAD patients. Women with MINOCA were younger (age 59.4 years vs 64.2 years; P < 0.001) and more diverse than those with MI-CAD. Women with MINOCA were less likely to have high stress (Perceived Stress Scale-4 ≥6) at the time of MI (51.0% vs 63.0%; P = 0.021) and at 2 months post-MI (32.5% vs 46.3%; P = 0.019) than women with MI-CAD. There was no difference in elevated depressive symptoms (Patient Health Questionnaire-2 ≥2) at the time of MI (36% vs 43%; P = 0.229) or at 2 months post-MI (39% vs 40%; P = 0.999). No differences in the rate of 2-month decline in stress and depression scores were observed between groups. CONCLUSIONS Stress and depression are common among women at the time of and 2 months after MI. MINOCA patients were less likely to report high stress compared with MI-CAD patients, but the frequency of elevated depressive symptoms did not differ between the 2 groups. Stress and depressive symptoms decreased in both MI-CAD and MINOCA patients over time.
Collapse
Affiliation(s)
- Anaïs Hausvater
- Sarah Ross Soter Center for Women's Cardiovascular Research, NYU Grossman School of Medicine, New York, New York, USA; Leon H. Charney Division of Cardiology, Department of Medicine, NYU Grossman School of Medicine, New York, New York, USA.
| | - Tanya M Spruill
- Sarah Ross Soter Center for Women's Cardiovascular Research, NYU Grossman School of Medicine, New York, New York, USA; Division of Biostatistics, Department of Population Health, NYU Grossman School of Medicine, New York, New York, USA
| | - Yuhe Xia
- Division of Biostatistics, Department of Population Health, NYU Grossman School of Medicine, New York, New York, USA
| | - Nathaniel R Smilowitz
- Sarah Ross Soter Center for Women's Cardiovascular Research, NYU Grossman School of Medicine, New York, New York, USA; Leon H. Charney Division of Cardiology, Department of Medicine, NYU Grossman School of Medicine, New York, New York, USA; VA NY Harbor Health Care System, Department of Medicine, Section of Cardiology, New York, New York, USA
| | - Milla Arabadjian
- Sarah Ross Soter Center for Women's Cardiovascular Research, NYU Grossman School of Medicine, New York, New York, USA; Division of Biostatistics, Department of Population Health, NYU Grossman School of Medicine, New York, New York, USA; Center for Population and Health Services Research Department of Foundations of Medicine NYU Long Island School of Medicine, Mineola, New York, USA
| | - Binita Shah
- Leon H. Charney Division of Cardiology, Department of Medicine, NYU Grossman School of Medicine, New York, New York, USA; VA NY Harbor Health Care System, Department of Medicine, Section of Cardiology, New York, New York, USA
| | - Ki Park
- University of Florida, Division of Cardiovascular Medicine, Malcom Randall VA Medical Center, Gainesville, Florida, USA
| | | | - Kevin Marzo
- New York University Winthrop Hospital, New York University Long Island School of Medicine, Mineola, New York, USA
| | - Dwithiya Thomas
- St Luke's University Healthcare, Bethlehem, Pennsylvania, USA
| | - Janet Wei
- Barbra Streisand Women's Heart Center, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Jeffrey Trost
- Johns Hopkins Medical Center, Baltimore, Maryland, USA
| | - Puja K Mehta
- Emory Clinical Cardiovascular Research Institute, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Bryan Har
- Libin Cardiovascular Institute, University of Calgary, Calgary, Alberta, Canada
| | - Kevin R Bainey
- Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Alberta, Canada
| | - Hua Zhong
- Division of Biostatistics, Department of Population Health, NYU Grossman School of Medicine, New York, New York, USA
| | - Judith S Hochman
- Sarah Ross Soter Center for Women's Cardiovascular Research, NYU Grossman School of Medicine, New York, New York, USA; Leon H. Charney Division of Cardiology, Department of Medicine, NYU Grossman School of Medicine, New York, New York, USA
| | - Harmony R Reynolds
- Sarah Ross Soter Center for Women's Cardiovascular Research, NYU Grossman School of Medicine, New York, New York, USA; Leon H. Charney Division of Cardiology, Department of Medicine, NYU Grossman School of Medicine, New York, New York, USA
| |
Collapse
|
12
|
Bainey KR, Marquis-Gravel G, MacDonald BJ, Bewick D, Yan A, Turgeon RD. Short dual antiplatelet therapy duration after percutaneous coronary intervention in high bleeding risk patients: Systematic review and meta-analysis. PLoS One 2023; 18:e0291061. [PMID: 37656721 PMCID: PMC10473507 DOI: 10.1371/journal.pone.0291061] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Accepted: 08/21/2023] [Indexed: 09/03/2023] Open
Abstract
INTRODUCTION Dual antiplatelet therapy (DAPT) following percutaneous coronary intervention (PCI) reduces major adverse cardiovascular events (MACE) and stent thrombosis. However, DAPT duration is a concern in high bleeding risk (HBR) patients. We evaluated the effect of short DAPT (1-3 months) compared to standard DAPT (6-12 months) on bleeding and ischemic events in HBR PCI. METHODS We searched MEDLINE, Embase and CENTRAL up to August 18, 2022. Randomized controlled trials (RCTs) comparing short DAPT (1-3 months) versus standard DAPT in HBR PCI were included. We assessed risk of bias (RoB) using the Cochrane RoB2 tool, and certainty of evidence using GRADE criteria. Outcomes included MACE, all-cause death, stent thrombosis, major bleeding, and the composite of major or clinically-relevant non-major bleeding. We estimated risk ratios (RR) and 95% confidence intervals (CI) using a random-effects model. RESULTS From 503 articles, we included five RCTs (n = 7,242) at overall low risk of bias with median follow-up of 12-months. Compared to standard DAPT, short DAPT did not increase MACE (RR 1.02, 95% CI 0.84-1.23), all-cause death (RR 0.92, 95% CI 0.71-1.20) or stent thrombosis (RR 1.47, 95% CI 0.73-2.93). Short DAPT reduced major bleeding (RR 0.34, 95% CI 0.13-0.90) and the composite of major or clinically-relevant non-major bleeding (RR 0.60, 95% CI 0.44-0.81), translating to 21 and 34 fewer events, respectively, per 1000 patients. CONCLUSIONS In HBR PCI, DAPT for 1-3 months compared to 6-12 months reduced clinically-relevant bleeding events without jeopardizing ischemic risk. Short DAPT should be considered in HBR patients receiving PCI.
Collapse
Affiliation(s)
- Kevin R. Bainey
- Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Alberta
| | | | - Blair J. MacDonald
- Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, British Columbia
| | - David Bewick
- New Brunswick Heart Center, Horizon Health Network, Saint John, New Brunswick
| | - Andrew Yan
- Division of Cardiology, Canadian Heart Research Centre and Terrence Donnelly Heart Centre, St Michael’s Hospital, University of Toronto, Toronto, Ontario
| | - Ricky D. Turgeon
- Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, British Columbia
| |
Collapse
|
13
|
Van de Werf F, Ristić AD, Averkov OV, Arias-Mendoza A, Lambert Y, Kerr Saraiva JF, Sepulveda P, Rosell-Ortiz F, French JK, Musić LB, Vandenberghe K, Bogaerts K, Westerhout CM, Pagès A, Danays T, Bainey KR, Sinnaeve P, Goldstein P, Welsh RC, Armstrong PW. STREAM-2: Half-Dose Tenecteplase or Primary Percutaneous Coronary Intervention in Older Patients With ST-Segment-Elevation Myocardial Infarction: A Randomized, Open-Label Trial. Circulation 2023; 148:753-764. [PMID: 37439219 DOI: 10.1161/circulationaha.123.064521] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Accepted: 06/16/2023] [Indexed: 07/14/2023]
Abstract
BACKGROUND ST-segment-elevation myocardial infarction (STEMI) guidelines recommend pharmaco-invasive treatment if timely primary percutaneous coronary intervention (PCI) is unavailable. Full-dose tenecteplase is associated with an increased risk of intracranial hemorrhage in older patients. Whether pharmaco-invasive treatment with half-dose tenecteplase is effective and safe in older patients with STEMI is unknown. METHODS STREAM-2 (Strategic Reperfusion in Elderly Patients Early After Myocardial Infarction) was an investigator-initiated, open-label, randomized, multicenter study. Patients ≥60 years of age with ≥2 mm ST-segment elevation in 2 contiguous leads, unable to undergo primary PCI within 1 hour, were randomly assigned (2:1) to half-dose tenecteplase followed by coronary angiography and PCI (if indicated) 6 to 24 hours after randomization, or to primary PCI. Efficacy end points of primary interest were ST resolution and the 30-day composite of death, shock, heart failure, or reinfarction. Safety assessments included stroke and nonintracranial bleeding. RESULTS Patients were assigned to pharmaco-invasive treatment (n=401) or primary PCI (n=203). Median times from randomization to tenecteplase or sheath insertion were 10 and 81 minutes, respectively. After last angiography, 85.2% of patients undergoing pharmaco-invasive treatment and 78.4% of patients undergoing primary PCI had ≥50% resolution of ST-segment elevation; their residual median sums of ST deviations were 4.5 versus 5.5 mm, respectively. Thrombolysis In Myocardial Infarction flow grade 3 at last angiography was ≈87% in both groups. The composite clinical end point occurred in 12.8% (51/400) of patients undergoing pharmaco-invasive treatment and 13.3% (27/203) of patients undergoing primary PCI (relative risk, 0.96 [95% CI, 0.62-1.48]). Six intracranial hemorrhages occurred in the pharmaco-invasive arm (1.5%): 3 were protocol violations (excess anticoagulation in 2 and uncontrolled hypertension in 1). No intracranial bleeding occurred in the primary PCI arm. The incidence of major nonintracranial bleeding was low in both groups (<1.5%). CONCLUSIONS Halving the dose of tenecteplase in a pharmaco-invasive strategy in this early-presenting, older STEMI population was associated with electrocardiographic changes that were at least comparable to those after primary PCI. Similar clinical efficacy and angiographic end points occurred in both treatment groups. The risk of intracranial hemorrhage was higher with half-dose tenecteplase than with primary PCI. If timely PCI is unavailable, this pharmaco-invasive strategy is a reasonable alternative, provided that contraindications to fibrinolysis are observed and excess anticoagulation is avoided. REGISTRATION URL: https://www. CLINICALTRIALS gov; Unique identifier: NCT02777580.
Collapse
Affiliation(s)
- Frans Van de Werf
- Department of Cardiovascular Sciences, KU Leuven, Belgium (F.V.d.W., K.V., P.S.)
| | - Arsen D Ristić
- Department of Cardiology, University Clinical Center of Serbia, University of Belgrade, Serbia (A.D.R)
| | - Oleg V Averkov
- Pirogov Russian National Research Medical University and City Clinical Hospital #15, Moscow, Russian Federation (O.V.A.)
| | | | - Yves Lambert
- Centre Hospitalier de Versailles, SAMU 78 and Mobile Intensive Care Unit, France (Y.L.)
| | - José F Kerr Saraiva
- Cardiology Discipline, Pontifical Catholic University of Campinas School of Medicine, Brazil (J.F.K.S.)
| | | | | | - John K French
- School of Medicine, University of New South Wales, Sydney, Department of Cardiology, Liverpool Hospital, Sydney, School of Medicine, Western Sydney University, New South Wales, Australia (J.K.F.)
| | - Ljilja B Musić
- Cardiology Clinic, University Clinical Center of Montenegro, University of Podgorica, Medical Faculty (L.B.M.)
| | - Katleen Vandenberghe
- Department of Cardiovascular Sciences, KU Leuven, Belgium (F.V.d.W., K.V., P.S.)
| | - Kris Bogaerts
- Interuniversity Institute for Biostatistics and statistical Bioinformatics (I-BioStat), KU Leuven, Leuven and University Hasselt, Belgium (K.B.)
| | - Cynthia M Westerhout
- The Canadian Virtual Coordinating Centre for Global Collaborative Cardiovascular Research {Canadian VIGOUR Centre}, University of Alberta, Edmonton (C.M.W., K.R.B., R.C.W., P.W.A.)
| | - Alain Pagès
- Boehringer Ingelheim GmbH, Ingelheim am Rhein, Germany (A.P.)
| | | | - Kevin R Bainey
- The Canadian Virtual Coordinating Centre for Global Collaborative Cardiovascular Research {Canadian VIGOUR Centre}, University of Alberta, Edmonton (C.M.W., K.R.B., R.C.W., P.W.A.)
| | - Peter Sinnaeve
- Department of Cardiovascular Sciences, KU Leuven, Belgium (F.V.d.W., K.V., P.S.)
| | - Patrick Goldstein
- Emergency Department and SAMU, Lille University Hospital, France (P.G.)
| | - Robert C Welsh
- The Canadian Virtual Coordinating Centre for Global Collaborative Cardiovascular Research {Canadian VIGOUR Centre}, University of Alberta, Edmonton (C.M.W., K.R.B., R.C.W., P.W.A.)
| | - Paul W Armstrong
- The Canadian Virtual Coordinating Centre for Global Collaborative Cardiovascular Research {Canadian VIGOUR Centre}, University of Alberta, Edmonton (C.M.W., K.R.B., R.C.W., P.W.A.)
| |
Collapse
|
14
|
Chow JK, Bagai A, Tan MK, Har BJ, Yip AMC, Paniagua M, Elbarouni B, Bainey KR, Paradis JM, Maranda R, Cantor WJ, Eisenberg MJ, Dery JP, Madan M, Cieza T, Matteau A, Roth S, Lavi S, Glanz A, Gao D, Tahiliani R, Welsh RC, Kim HH, Robinson SD, Daneault B, Chong AY, Le May MR, Ahooja V, Gregoire JC, Nadeau PL, Laksman Z, Heilbron B, Yung D, Minhas K, Bourgeois R, Overgaard CB, Bonakdar H, Logsetty G, Lavoie AJ, De LaRochelliere R, Mansour S, Spindler C, Yan AT, Goodman SG. Antithrombotic therapies in Canadian atrial fibrillation patients with concomitant coronary artery disease: Insights from the CONNECT AF + PCI-II program. J Cardiol 2023; 82:153-161. [PMID: 36931433 DOI: 10.1016/j.jjcc.2023.03.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2022] [Revised: 03/04/2023] [Accepted: 03/07/2023] [Indexed: 03/19/2023]
Abstract
BACKGROUND Selecting the appropriate antithrombotic regimen for patients with atrial fibrillation (AF) who have undergone percutaneous coronary intervention (PCI) or have had medically managed acute coronary syndrome (ACS) remains complex. This multi-centre observational study evaluated patterns of antithrombotic therapies utilized among Canadian patients with AF post-PCI or ACS. METHODS AND RESULTS By retrospective chart audit, 611 non-valvular AF patients [median (interquartile range) age 76 (69-83) years, CHADS2 score 2 (1-3)] who underwent PCI or had medically managed ACS between August 2018 and December 2020 were identified by 68 cardiologists across eight provinces in Canada. Overall, triple antithrombotic therapy [TAT: combined oral anticoagulation (OAC) and dual antiplatelet therapy (DAPT)] was the most common initial antithrombotic strategy, with use in 53.8 % of patients, followed by dual pathway therapy (32.7 % received OAC and a P2Y12 inhibitor, and 4.1 % received OAC and aspirin) and DAPT (9.3 %). Median duration of TAT was 30 (7, 30) days. Compared to the previous CONNECT AF + PCI-I program, there was an increased use of dual pathway therapy relative to TAT over time (P-value <.0001). DOACs (direct oral anticoagulants) represented 90.3 % of all OACs used overall, with apixaban being the most utilized (50.5 %). Proton pump inhibitors were used in 57.0 % of all patients, and 70.1 % of patients on ASA. Planned antithrombotic therapies at 1 year were: 76.2 % OAC monotherapy, 8.3 % OAC + ASA, 7.9 % OAC + P2Y12 inhibitor, 4.3 % DAPT, 1.3 % ASA alone, and <1 % triple therapy. CONCLUSION In accordance with recent Canadian Cardiovascular Society guideline recommendations, we observed an increased use of dual pathway therapy relative to TAT over time in both AF patients post-PCI (elective and emergent) and in those with medically managed ACS. Additionally, DOACs have become the prevailing form of anticoagulation across all antithrombotic regimens. Our findings suggest that Canadian physicians are integrating evidence-based approaches to optimally manage the bleeding and thrombotic risks of AF patients post-PCI and/or ACS.
Collapse
Affiliation(s)
| | - Akshay Bagai
- University of Toronto, Toronto, Canada; St Michael's Hospital, Toronto, Canada
| | - Mary K Tan
- Canadian Heart Research Centre, Toronto, Canada
| | - Bryan J Har
- Libin Cardiovascular Institute, University of Calgary, Calgary, Canada
| | | | | | - Basem Elbarouni
- St Boniface Hospital, University of Manitoba, Winnipeg, Canada
| | - Kevin R Bainey
- Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Canada
| | - Jean-Michel Paradis
- Institut universitaire de cardiologie et de pneumologie de Québec, Laval University, Quebec, Canada
| | | | - Warren J Cantor
- University of Toronto, Toronto, Canada; Southlake Regional Health Centre, Newmarket, Canada
| | | | - Jean-Pierre Dery
- Institut universitaire de cardiologie et de pneumologie de Québec, Laval University, Quebec, Canada
| | - Mina Madan
- University of Toronto, Toronto, Canada; Schulich Heart Centre, Sunnybrook Health Sciences Centre, Toronto, Canada
| | - Tomas Cieza
- Institut universitaire de cardiologie et de pneumologie de Québec, Laval University, Quebec, Canada
| | - Alexis Matteau
- Centre hospitalier de l'université de Montréal (CHUM), Montreal, Canada
| | - Sherryn Roth
- Schulich Heart Centre, Sunnybrook Health Sciences Centre, Toronto, Canada; Scarborough Health Network, Toronto, Canada
| | | | | | | | - Ravi Tahiliani
- Central East Regional Cardiac Care Program, Oshawa, Canada
| | - Robert C Welsh
- Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Canada
| | - Hahn Hoe Kim
- St. Mary's General Hospital, Kitchener-Waterloo, Canada
| | - Simon D Robinson
- Royal Jubilee Hospital, University of British Columbia, Victoria, Canada
| | - Benoit Daneault
- Centre hospitalier Universitaire de Sherbrooke, Sherbrooke University, Sherbrooke, Canada
| | | | | | | | | | | | | | - Brett Heilbron
- University of British Columbia, Vancouver, Canada; St. Paul's Hospital, Vancouver, Canada
| | - Derek Yung
- Scarborough Health Network, Toronto, Canada
| | - Kunal Minhas
- St Boniface Hospital, University of Manitoba, Winnipeg, Canada
| | - Ronald Bourgeois
- Moncton Hospital, Dalhousie University Faculty of Medicine, Moncton, Canada
| | | | - Hamid Bonakdar
- St Boniface Hospital, University of Manitoba, Winnipeg, Canada
| | | | - Andrea J Lavoie
- Regina General Hospital - Prairie Vascular Research Network, Regina, Canada
| | - Robert De LaRochelliere
- Institut universitaire de cardiologie et de pneumologie de Québec, Laval University, Quebec, Canada
| | - Samer Mansour
- Centre hospitalier de l'université de Montréal (CHUM), Montreal, Canada
| | | | - Andrew T Yan
- University of Toronto, Toronto, Canada; St Michael's Hospital, Toronto, Canada.
| | - Shaun G Goodman
- University of Toronto, Toronto, Canada; St Michael's Hospital, Toronto, Canada; Canadian Heart Research Centre, Toronto, Canada.
| |
Collapse
|
15
|
Shavadia JS, Stanberry L, Singh J, Thao KR, Ghasemzadeh N, Mercado N, Nayak KR, Alraies MC, Bagur R, Saw J, Bagai A, Bainey KR, Madan M, Amlani S, Garberich R, Grines CL, Garcia S, Henry TD, Dehghani P. Comparative Analysis of Patients With STEMI and COVID-19 Between Canada and the United States. J Soc Cardiovasc Angiogr Interv 2023:100970. [PMID: 37363317 PMCID: PMC10284462 DOI: 10.1016/j.jscai.2023.100970] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 01/25/2023] [Revised: 03/17/2023] [Accepted: 03/20/2023] [Indexed: 06/28/2023]
Abstract
Background Important health care differences exist between the United States (US) and Canada, which may have been exacerbated during the pandemic. We compared clinical characteristics, treatment strategies, and clinical outcomes of patients with ST-segment elevation myocardial infarction (STEMI) and COVID-19 (STEMI-COVID) treated in the US and Canada. Methods The North American COVID-19 Myocardial Infarction registry is a prospective, investigator-initiated study enrolling patients with STEMI with confirmed or suspected COVID-19 in the US and Canada. The primary end point was in-hospital mortality. Additionally, we explored associations between vaccination and clinical outcomes. Results Of 853 patients with STEMI-COVID, 112 (13%) were enrolled in Canada, and compared with the US, patients in Canada were more likely to present with chest pain and less likely to have a history of heart failure, stroke/transient ischemic attack, pulmonary infiltrates or renal failure. In both countries, the primary percutaneous coronary intervention was the dominant reperfusion strategy, with no difference in door-to-balloon times; fibrinolysis was used less frequently in the US than in Canada. The adjusted in-hospital mortality was not different between the 2 countries (relative risk [RR], 1.0; 95% CI, 0.46-2.72; P = 1.0). However, the risk of in-hospital mortality was significantly higher in unvaccinated compared with vaccinated patients with STEMI-COVID (RR, 4.7; 95% CI, 1.7-11.53; P = .015). Conclusions Notable differences in morbidities and reperfusion strategies were evident between patients with STEMI-COVID in the US compared with Canada. No differences were noted for in-hospital mortality. Vaccination, regardless of region, appeared to associate with a lower risk of in-hospital mortality strongly.
Collapse
Affiliation(s)
- Jay S Shavadia
- Division of Cardiology, Department of Medicine, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | | | - Jyotpal Singh
- Prairie Vascular Research Inc, Regina, Saskatchewan, Canada
| | | | - Nima Ghasemzadeh
- Georgia Heart Institute, Northeast Georgia Medical Center, Gainesville, Georgia
| | | | - Keshav R Nayak
- Department of Cardiology, Scripps Mercy Hospital, San Diego, California
| | | | - Rodrigo Bagur
- Division of Cardiology, Department of Medicine, London Health Sciences Centre, Western University, London, Ontario, Canada
| | - Jacqueline Saw
- Vancouver General Hospital, Vancouver, British Columbia, Canada
| | | | - Kevin R Bainey
- University of Alberta, Mazankowski Alberta Heart Institute, Edmonton, Alberta, Canada
| | - Mina Madan
- Schulich Heart Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Shy Amlani
- William Osler Health System, Brampton, Ontario, Canada
| | - Ross Garberich
- Minneapolis Heart Institute Foundation, Minneapolis, Minnesota
| | | | - Santiago Garcia
- Minneapolis Heart Institute Foundation, Minneapolis, Minnesota
| | - Timothy D Henry
- The Carl and Edyth Lindner Center for Research and Education, The Christ Hospital, Cincinnati, Ohio
| | - Payam Dehghani
- Prairie Vascular Research Inc, Regina, Saskatchewan, Canada
| |
Collapse
|
16
|
Behrouzi B, Sivaswamy A, Chu A, Ferreira-Legere LE, Abdel-Qadir H, Atzema CL, Jackevicius C, Kapral MK, Wijeysundera HC, Farkouh ME, Ross HJ, Ha ACT, Tadrous M, Paterson M, Gershon AS, Džavík V, Fang J, Kaul P, van Diepen S, Goodman SG, Ezekowitz JA, Bainey KR, Ko DT, Austin PC, McAlister FA, Lee DS, Udell JA. Sex-Based Differences in Severe Outcomes, Including Cardiovascular Hospitalization, in Adults With COVID-19 in Ontario, Canada. JACC Adv 2023; 2:100307. [PMID: 37250382 PMCID: PMC10171238 DOI: 10.1016/j.jacadv.2023.100307] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Revised: 12/30/2022] [Accepted: 02/08/2023] [Indexed: 05/31/2023]
Abstract
Background While men have experienced higher risks of SARS-CoV-2 infection compared to women, an analysis of sex differences by age in severe outcomes during the acute phase of infection is lacking. Objectives The purpose of this study was to assess heterogeneity in severe outcome risks by age and sex by conducting a retrospective cohort study of community-dwelling adults in Ontario who tested positive for SARS-CoV-2 infection during the first 3 waves. Methods Adjusted odds ratios were estimated using multilevel multivariable logistic regression models including an interaction term for age and sex. The primary outcome was a composite of severe outcomes (hospitalization for a cardiovascular (CV) event, intensive care unit admission, mechanical ventilation, or death) within 30 days. Results Among 30,736, 199,132, and 186,131 adults who tested positive during the first 3 waves, 1,908 (6.2%), 5,437 (2.7%), and 5,653 (3.0%) experienced a severe outcome within 30 days. For all outcomes, the sex-specific risk depended on age (all P for interaction <0.05). Men with SARS-CoV-2 infection experienced a higher risk of outcomes than infected women of the same age, except for the risk of all-cause hospitalization being higher for young women than men (ages 18-45 years) during waves 2 and 3. The sex disparity in CV hospitalization across all ages either persisted or increased with each subsequent wave. Conclusions To mitigate risks in subsequent waves, it is helpful to further understand the factors that contribute to the generally higher risks faced by men across all ages, and the persistent or increasing sex disparity in the risk of CV hospitalization.
Collapse
Affiliation(s)
- Bahar Behrouzi
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada
- Temerty Faculty of Medicine, University of Toronto, Toronto, Canada
- ICES, Toronto, Canada
- Cardiovascular Division, Department of Medicine, Women's College Hospital, Toronto, Canada
| | | | | | | | - Husam Abdel-Qadir
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada
- Temerty Faculty of Medicine, University of Toronto, Toronto, Canada
- ICES, Toronto, Canada
- Cardiovascular Division, Department of Medicine, Women's College Hospital, Toronto, Canada
- Department of Medicine, University of Toronto, Toronto, Canada
| | - Clare L Atzema
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada
- ICES, Toronto, Canada
- Department of Medicine, University of Toronto, Toronto, Canada
- Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Canada
| | - Cynthia Jackevicius
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada
- ICES, Toronto, Canada
- College of Pharmacy, Western University of Health Sciences, Pomona, California, USA
| | - Moira K Kapral
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada
- Temerty Faculty of Medicine, University of Toronto, Toronto, Canada
- ICES, Toronto, Canada
- Department of Medicine, University of Toronto, Toronto, Canada
| | - Harindra C Wijeysundera
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada
- Temerty Faculty of Medicine, University of Toronto, Toronto, Canada
- ICES, Toronto, Canada
- Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Canada
| | - Michael E Farkouh
- Peter Munk Cardiac Centre, University Health Network, Toronto, Canada
- Heart and Stroke Richard Lewar Centre, University of Toronto, Toronto, Canada
| | - Heather J Ross
- Temerty Faculty of Medicine, University of Toronto, Toronto, Canada
- Peter Munk Cardiac Centre, University Health Network, Toronto, Canada
| | - Andrew C T Ha
- Department of Medicine, University of Toronto, Toronto, Canada
- Peter Munk Cardiac Centre, University Health Network, Toronto, Canada
| | - Mina Tadrous
- ICES, Toronto, Canada
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Canada
- Women's College Research Institute, Toronto, Canada
| | - Michael Paterson
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada
- ICES, Toronto, Canada
| | - Andrea S Gershon
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada
- ICES, Toronto, Canada
- Department of Medicine, University of Toronto, Toronto, Canada
- Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Canada
| | - Vladimír Džavík
- Peter Munk Cardiac Centre, University Health Network, Toronto, Canada
| | | | - Padma Kaul
- Canadian VIGOUR Centre, University of Alberta, Edmonton, Canada
- Department of Medicine, Faculty of Medicine & Dentistry, University of Alberta, Edmonton, Canada
- Department of Critical Care Medicine and Division of Cardiology, Department of Medicine, University of Alberta, Edmonton, Canada
| | - Sean van Diepen
- Canadian VIGOUR Centre, University of Alberta, Edmonton, Canada
- Department of Medicine, Faculty of Medicine & Dentistry, University of Alberta, Edmonton, Canada
- Department of Critical Care Medicine and Division of Cardiology, Department of Medicine, University of Alberta, Edmonton, Canada
| | - Shaun G Goodman
- Department of Medicine, University of Toronto, Toronto, Canada
- Canadian VIGOUR Centre, University of Alberta, Edmonton, Canada
- Division of Cardiology, St. Michael's Hospital, Toronto, Canada
| | - Justin A Ezekowitz
- Canadian VIGOUR Centre, University of Alberta, Edmonton, Canada
- Department of Medicine, Faculty of Medicine & Dentistry, University of Alberta, Edmonton, Canada
- Department of Critical Care Medicine and Division of Cardiology, Department of Medicine, University of Alberta, Edmonton, Canada
| | - Kevin R Bainey
- Canadian VIGOUR Centre, University of Alberta, Edmonton, Canada
- Department of Medicine, Faculty of Medicine & Dentistry, University of Alberta, Edmonton, Canada
- Department of Critical Care Medicine and Division of Cardiology, Department of Medicine, University of Alberta, Edmonton, Canada
| | - Dennis T Ko
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada
- ICES, Toronto, Canada
- Department of Medicine, University of Toronto, Toronto, Canada
- Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Canada
| | - Peter C Austin
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada
- ICES, Toronto, Canada
| | - Finlay A McAlister
- Canadian VIGOUR Centre, University of Alberta, Edmonton, Canada
- Department of Medicine, Faculty of Medicine & Dentistry, University of Alberta, Edmonton, Canada
- Department of Critical Care Medicine and Division of Cardiology, Department of Medicine, University of Alberta, Edmonton, Canada
| | - Douglas S Lee
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada
- ICES, Toronto, Canada
- Department of Medicine, University of Toronto, Toronto, Canada
- Peter Munk Cardiac Centre, University Health Network, Toronto, Canada
| | - Jacob A Udell
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada
- ICES, Toronto, Canada
- Cardiovascular Division, Department of Medicine, Women's College Hospital, Toronto, Canada
- Department of Medicine, University of Toronto, Toronto, Canada
- Peter Munk Cardiac Centre, University Health Network, Toronto, Canada
| |
Collapse
|
17
|
Mehta SR, Wang J, Wood DA, Spertus JA, Cohen DJ, Mehran R, Storey RF, Steg PG, Pinilla-Echeverri N, Sheth T, Bainey KR, Bangalore S, Cantor WJ, Faxon DP, Feldman LJ, Jolly SS, Kunadian V, Lavi S, Lopez-Sendon J, Madan M, Moreno R, Rao SV, Rodés-Cabau J, Stanković G, Bangdiwala SI, Cairns JA. Complete Revascularization vs Culprit Lesion-Only Percutaneous Coronary Intervention for Angina-Related Quality of Life in Patients With ST-Segment Elevation Myocardial Infarction: Results From the COMPLETE Randomized Clinical Trial. JAMA Cardiol 2022; 7:1091-1099. [PMID: 36129696 PMCID: PMC9494273 DOI: 10.1001/jamacardio.2022.3032] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Accepted: 07/25/2022] [Indexed: 01/09/2023]
Abstract
Importance In patients with multivessel coronary artery disease (CAD) presenting with ST-segment elevation myocardial infarction (STEMI), complete revascularization reduces major cardiovascular events compared with culprit lesion-only percutaneous coronary intervention (PCI). Whether complete revascularization also improves angina-related health status is unknown. Objective To determine whether complete revascularization improves angina status in patients with STEMI and multivessel CAD. Design, Setting, and Participants This secondary analysis of a randomized, multinational, open label trial of patient-reported outcomes took place in 140 primary PCI centers in 31 countries. Patients presenting with STEMI and multivessel CAD were randomized between February 1, 2013, and March 6, 2017. Analysis took place between July 2021 and December 2021. Interventions Following PCI of the culprit lesion, patients with STEMI and multivessel CAD were randomized to receive either complete revascularization with additional PCI of angiographically significant nonculprit lesions or to no further revascularization. Main Outcomes and Measures Seattle Angina Questionnaire Angina Frequency (SAQ-AF) score (range, 0 [daily angina] to 100 [no angina]) and the proportion of angina-free individuals by study end. Results Of 4041 patients, 2016 were randomized to complete revascularization and 2025 to culprit lesion-only PCI. The mean (SD) age of patients was 62 (10.7) years, and 3225 (80%) were male. The mean (SD) SAQ-AF score increased from 87.1 (17.8) points at baseline to 97.1 (9.7) points at a median follow-up of 3 years in the complete revascularization group (score change, 9.9 [95% CI, 9.0-10.8]; P < .001) compared with an increase of 87.2 (18.4) to 96.3 (10.9) points (score change, 8.9 [95% CI, 8.0-9.8]; P < .001) in the culprit lesion-only group (between-group difference, 0.97 points [95% CI, 0.27-1.67]; P = .006). Overall, 1457 patients (87.5%) were free of angina (SAQ-AF score, 100) in the complete revascularization group compared with 1376 patients (84.3%) in the culprit lesion-only group (absolute difference, 3.2% [95% CI, 0.7%-5.7%]; P = .01). This benefit was observed mainly in patients with nonculprit lesion stenosis severity of 80% or more (absolute difference, 4.7%; interaction P = .02). Conclusions and Relevance In patients with STEMI and multivessel CAD, complete revascularization resulted in a slightly greater proportion of patients being angina-free compared with a culprit lesion-only strategy. This modest incremental improvement in health status is in addition to the established benefit of complete revascularization in reducing cardiovascular events.
Collapse
Affiliation(s)
- Shamir R. Mehta
- Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - Jia Wang
- Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - David A. Wood
- University of British Columbia, Vancouver, British Columbia, Canada
| | - John A. Spertus
- Saint Luke’s Mid America Heart Institute and the University of Missouri–Kansas City, Kansas City
| | - David J. Cohen
- Cardiovascular Research Foundation, New York, New York
- St Francis Hospital, Roslyn, New York
| | - Roxana Mehran
- The Zena A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Robert F. Storey
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, United Kingdom
| | - Philippe Gabriel Steg
- Université Paris Cité, INSERM U-1148, Hôpital Bichat, Assistance Publique-Hôpitaux de Paris, Paris, France and FACT (French Alliance for Cardiovascular Trials), Paris, France
| | - Natalia Pinilla-Echeverri
- Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - Tej Sheth
- Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - Kevin R. Bainey
- University of Alberta, Mazankowski Alberta Heart Institute, Edmonton, Alberta, Canada
| | | | - Warren J. Cantor
- Southlake Regional Health Centre, University of Toronto, Toronto, Ontario, Canada
| | - David P. Faxon
- Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts
| | - Laurent J. Feldman
- Université Paris Cité, INSERM U-1148, Hôpital Bichat, Assistance Publique-Hôpitaux de Paris, Paris, France and FACT (French Alliance for Cardiovascular Trials), Paris, France
| | - Sanjit S. Jolly
- Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - Vijay Kunadian
- Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University and Cardiothoracic Centre, Freeman Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, United Kingdom
| | - Shahar Lavi
- Western University, London Health Sciences Centre, London, Ontario, Canada
| | - Jose Lopez-Sendon
- Hospital Universitario La Paz, UAM, IdiPaz Research Institute, Madrid, Spain
| | - Mina Madan
- Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Raul Moreno
- Hospital Universitario La Paz, UAM, IdiPaz Research Institute, Madrid, Spain
| | | | - Josep Rodés-Cabau
- Institut Universitaire de Cardiologie et de Pneumologie de Québec, Québec City, Quebec, Canada
| | - Goran Stanković
- Serbia to Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - Shrikant I. Bangdiwala
- Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - John A. Cairns
- University of British Columbia, Vancouver, British Columbia, Canada
| |
Collapse
|
18
|
Bainey KR, Marquis-Gravel G, Mehta SR, Tanguay JF. The Evolution of Anticoagulation for Percutaneous Coronary Intervention: A 40-Year Journey. Can J Cardiol 2022; 38:S89-S98. [PMID: 35850382 DOI: 10.1016/j.cjca.2022.07.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2022] [Revised: 07/09/2022] [Accepted: 07/12/2022] [Indexed: 12/30/2022] Open
Abstract
The selection of antithrombotic strategies continue to be of utmost importance during percutaneous coronary intervention (PCI) and have evolved over the past 40 years. Although the backbone of therapy during PCI continues to be a combination of oral antiplatelets and parenteral anticoagulants, a variety of different approaches have been tested over time. In particular, different choices of anticoagulation management have been tested in the stable ischemic heart disease and acute coronary syndrome setting. Evaluation of alternative regimens in the quest to balance ischemic and bleeding risk have undoubtedly improved patient care with PCI. In the current review we highlight the evolution of evidence-based therapeutic options over the past 40 years from the beginning of coronary angioplasty to contemporary PCI. We provide insight into future therapeutic options and provide a contemporary overview of anticoagulation choices for patients who require PCI on the basis of up-to-date evidence balancing ischemic and bleeding risk and according to clinical presentation.
Collapse
Affiliation(s)
- Kevin R Bainey
- Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Alberta, Canada.
| | | | - Shamir R Mehta
- Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, Ontario, Canada
| | | |
Collapse
|
19
|
Marquis-Gravel G, Robert-Halabi M, Bainey KR, Tanguay JF, Mehta SR. The Evolution of Antiplatelet Therapy After Percutaneous Coronary Interventions: A 40-Year Journey. Can J Cardiol 2022; 38:S79-S88. [PMID: 35231553 DOI: 10.1016/j.cjca.2022.02.022] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Revised: 02/05/2022] [Accepted: 02/22/2022] [Indexed: 12/30/2022] Open
Abstract
Antiplatelet therapy has a critical role to play in the successful management of patients undergoing percutaneous coronary intervention (PCI). Over the past 40 years, a multitude of participants worldwide have been enrolled in trials evaluating the impact of antiplatelet agents on clinical outcomes. The use of aspirin in unstable angina in the Canadian Aspirin trial was key to establishing the benefit of aspirin in acute coronary syndrome. The Clopidogrel in Unstable Angina to Prevent Recurrent Events (CURE) trial demonstrated that the P2Y12 inhibitor clopidogrel, when added to aspirin, reduced major cardiovascular events. While the use of antiplatelet agents in coronary artery disease antedates the introduction of PCI and remains the cornerstone of secondary prevention of atherosclerotic cardiovascular disease, strategies aiming to optimise their best use are still constantly evolving. In this review, the major randomised trials shaping current clinical practice for the use of aspirin and P2Y12 inhibitors in patients undergoing PCI are summarised, with a focus on aspirin-free strategies and on the role of P2Y12 inhibitor treatment before PCI, two major topics of ongoing investigation that are critical to patient care but that are not addressed in current practice guidelines. Multiple questions remain regarding the use of antiplatelet agents after PCI, including the personalisation of dosing, intensity, pharmacologic formulation, and duration of antiplatelet therapy based on individual patient characteristics and the optimal treatment of patients at high bleeding risk.
Collapse
Affiliation(s)
| | | | - Kevin R Bainey
- Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Alberta, Canada
| | | | - Shamir R Mehta
- Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, Ontario, Canada.
| |
Collapse
|
20
|
Bainey KR, Bastiany A, Cohen E, Eckstein J, Elbarouni B, Graham MM, Kidwai B, Liu S, Mansour S, Matteau A, O'Neill B, Sathananthan J, Sibbald M, Welsh RC, Madan M. 2022 CCS/CAIC Guidelines for Training and Retraining in Adult Interventional Cardiology. Can J Cardiol 2022; 38:1307-1311. [PMID: 35257823 DOI: 10.1016/j.cjca.2022.02.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2022] [Revised: 02/26/2022] [Accepted: 02/22/2022] [Indexed: 12/14/2022] Open
Affiliation(s)
- Kevin R Bainey
- Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Alberta, Canada.
| | - Alexandra Bastiany
- Thunder Bay Regional Health Sciences Centre, Thunder Bay, Ontario, Canada
| | - Eric Cohen
- Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Janine Eckstein
- Royal University Hospital, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Basem Elbarouni
- Cardiac Sciences Manitoba, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Michelle M Graham
- Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Alberta, Canada
| | | | - Shuangbo Liu
- Cardiac Sciences Manitoba, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Samer Mansour
- Centre Hospitalier de l'Université de Montréal, Université de Montréal, Montréal, Québec, Canada
| | - Alexis Matteau
- Centre Hospitalier de l'Université de Montréal, Université de Montréal, Montréal, Québec, Canada
| | - Blair O'Neill
- Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Alberta, Canada
| | - Janarthanan Sathananthan
- Centre for Cardiovascular Innovation, University of British Columbia, Vancouver, British Columbia, Canada
| | | | - Robert C Welsh
- Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Alberta, Canada
| | - Mina Madan
- Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| |
Collapse
|
21
|
Chaitman BR, Cyr DD, Alexander KP, Pracoń R, Bainey KR, Mathew A, Acharya A, Kunichoff DF, Fleg JL, Lopes RD, Sidhu MS, Anthopolos R, Rockhold FW, Stone GW, Maron DJ, Hochman JS, Bangalore S. Cardiovascular and Renal Implications of Myocardial Infarction in the ISCHEMIA-CKD Trial. Circ Cardiovasc Interv 2022; 15:e012103. [PMID: 35973009 PMCID: PMC10865178 DOI: 10.1161/circinterventions.122.012103] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND ISCHEMIA-CKD (International Study of Comparative Health Effectiveness With Medical and Invasive Approaches-Chronic Kidney Disease) reported an initial invasive treatment strategy did not reduce the risk of death or nonfatal myocardial infarction (MI) compared with a conservative treatment strategy in patients with advanced chronic kidney disease, stable coronary disease, and moderate or severe myocardial ischemia. The cumulative frequency of different MI type after randomization and subsequent prognosis have not been reported. METHODS MI classification was based on the Third Universal Definition for MI. For procedural MI, the primary MI definition used creatine kinase-MB as the preferred biomarker, whereas the secondary MI definition used cTn (cardiac troponin); both definitions included elevated biomarker-only events with higher thresholds than nonprocedural MIs. The cumulative frequency of MI type according to treatment strategy was determined. The association of MI with subsequent all-cause death and new dialysis initiation was assessed by treating MI as a time-dependent covariate. RESULTS The 3-year incidence of type 1 or 2 MI with the primary MI definition was 11.2% in invasive treatment strategy and 13.6% in conservative treatment strategy (hazard ratio [HR], 0.66 [95% CI, 0.42-1.02]). Procedural MIs were more frequent in invasive treatment strategy and accounted for 9.8% and 28.3% of all MIs with the primary and secondary MI definitions, respectively. Patients had an increased risk of all-cause death after type 1 MI (adjusted HR, 4.35 [95% CI, 2.73-6.93]) and after procedural MI with the primary (adjusted HR, 2.75 [95% CI, 0.99-7.60]) and secondary MI definitions (adjusted HR, 2.91 [95% CI, 1.73-4.88]). Dialysis initiation was increased after a type 1 MI (HR, 6.45 [95% CI, 2.59-16.08]) compared with patients without an MI. CONCLUSIONS In ISCHEMIA-CKD, the invasive treatment strategy had higher rates of procedural MIs, particularly with the secondary MI definition, and lower rates of type 1 and 2 MIs. Procedural MIs, type 1 MIs, and type 2 MIs were associated with increased risk of subsequent death. Type 1 MI increased the risk of dialysis initiation. REGISTRATION URL: https://www. CLINICALTRIALS gov; Unique identifier: NCT01985360.
Collapse
Affiliation(s)
| | - Derek D. Cyr
- Duke Clinical Research Institute and Duke University, Durham, NC, USA
| | | | - Radosław Pracoń
- Coronary and Structural Heart Diseases Department, Institute of Cardiology, Mazowieckie, Poland
| | - Kevin R. Bainey
- Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Canada
| | - Anoop Mathew
- MOSC Medical College Hospital, Kolenchery, India
| | | | | | - Jerome L. Fleg
- National National Heart Lung and Blood Institute, Bethesda, MD, USA
| | - Renato D. Lopes
- Duke Clinical Research Institute and Duke University, Durham, NC, USA
| | | | | | - Frank W. Rockhold
- Duke Clinical Research Institute and Duke University, Durham, NC, USA
| | - Gregg W. Stone
- Icahn School of Medicine at Mount Sinai, New York, NY, USA and the Cardiovascular Research Foundation, New York, NY, USA
| | - David J. Maron
- Stanford University School of Medicine, Stanford, CA, USA
| | | | | |
Collapse
|
22
|
Udell JA, Behrouzi B, Sivaswamy A, Chu A, Ferreira-Legere LE, Fang J, Goodman SG, Ezekowitz JA, Bainey KR, van Diepen S, Kaul P, McAlister FA, Bogoch II, Jackevicius CA, Abdel-Qadir H, Wijeysundera HC, Ko DT, Austin PC, Lee DS. Clinical risk, sociodemographic factors, and SARS-CoV-2 infection over time in Ontario, Canada. Sci Rep 2022; 12:10534. [PMID: 35750706 PMCID: PMC9232511 DOI: 10.1038/s41598-022-13598-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Accepted: 05/25/2022] [Indexed: 01/08/2023] Open
Abstract
We aimed to determine whether early public health interventions in 2020 mitigated the association of sociodemographic and clinical risk factors with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. We conducted a population-based cohort study of all adults in Ontario, Canada who underwent testing for SARS-CoV-2 through December 31, 2020. The outcome was laboratory-confirmed SARS-CoV-2 infection, determined by reverse transcription polymerase chain reaction testing. Adjusted odds ratios (ORs) were determined for sociodemographic and clinical risk factors before and after the first-wave peak of the pandemic to assess for changes in effect sizes. Among 3,167,753 community-dwelling individuals, 142,814 (4.5%) tested positive. The association between age and SARS-CoV-2 infection risk varied over time (P-interaction < 0.0001). Prior to the first-wave peak, SARS-CoV-2 infection increased with age whereas this association reversed thereafter. Risk factors that persisted included male sex, residing in lower income neighborhoods, residing in more racially/ethnically diverse communities, immigration to Canada, hypertension, and diabetes. While there was a reduction in infection rates after mid-April 2020, there was less impact in regions with higher racial/ethnic diversity. Immediately following the initial peak, individuals living in the most racially/ethnically diverse communities with 2, 3, or ≥ 4 risk factors had ORs of 1.89, 3.07, and 4.73-fold higher for SARS-CoV-2 infection compared to lower risk individuals in their community (all P < 0.0001). In the latter half of 2020, this disparity persisted with corresponding ORs of 1.66, 2.48, and 3.70-fold higher, respectively. In the least racially/ethnically diverse communities, there was little/no gradient in infection rates across risk strata. Further efforts are necessary to reduce the risk of SARS-CoV-2 infection among the highest risk individuals residing in the most racially/ethnically diverse communities.
Collapse
Affiliation(s)
- Jacob A Udell
- ICES, Toronto, Canada. .,Cardiovascular Division, Department of Medicine, Women's College Hospital, Toronto, Canada. .,Peter Munk Cardiac Centre, University Health Network, Toronto, Canada. .,Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Canada. .,Department of Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, Canada.
| | - Bahar Behrouzi
- ICES, Toronto, Canada.,Cardiovascular Division, Department of Medicine, Women's College Hospital, Toronto, Canada.,Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Canada.,Department of Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, Canada
| | | | | | | | | | - Shaun G Goodman
- Department of Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, Canada.,Division of Cardiology, St. Michael's Hospital, Toronto, Canada.,Canadian VIGOUR Centre, University of Alberta, Edmonton, Canada
| | - Justin A Ezekowitz
- Canadian VIGOUR Centre, University of Alberta, Edmonton, Canada.,Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Canada.,Department of Critical Care Medicine and Division of Cardiology, Department of Medicine, University of Alberta, Edmonton, Canada
| | - Kevin R Bainey
- Canadian VIGOUR Centre, University of Alberta, Edmonton, Canada.,Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Canada.,Department of Critical Care Medicine and Division of Cardiology, Department of Medicine, University of Alberta, Edmonton, Canada
| | - Sean van Diepen
- Canadian VIGOUR Centre, University of Alberta, Edmonton, Canada.,Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Canada.,Department of Critical Care Medicine and Division of Cardiology, Department of Medicine, University of Alberta, Edmonton, Canada
| | - Padma Kaul
- Canadian VIGOUR Centre, University of Alberta, Edmonton, Canada.,Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Canada.,Department of Critical Care Medicine and Division of Cardiology, Department of Medicine, University of Alberta, Edmonton, Canada
| | - Finlay A McAlister
- Canadian VIGOUR Centre, University of Alberta, Edmonton, Canada.,Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Canada.,Department of Critical Care Medicine and Division of Cardiology, Department of Medicine, University of Alberta, Edmonton, Canada
| | - Isaac I Bogoch
- Department of Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, Canada.,Divisions of General Internal Medicine and Infectious Diseases, University Health Network, Toronto, Canada
| | - Cynthia A Jackevicius
- ICES, Toronto, Canada.,Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Canada.,Western University of Health Sciences, Pomona, CA, USA
| | - Husam Abdel-Qadir
- ICES, Toronto, Canada.,Cardiovascular Division, Department of Medicine, Women's College Hospital, Toronto, Canada.,Peter Munk Cardiac Centre, University Health Network, Toronto, Canada.,Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Canada.,Department of Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, Canada
| | - Harindra C Wijeysundera
- ICES, Toronto, Canada.,Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Canada.,Department of Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, Canada.,Schulich Heart Centre, Sunnybrook Health Sciences Centre, Toronto, Canada
| | - Dennis T Ko
- ICES, Toronto, Canada.,Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Canada.,Department of Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, Canada.,Schulich Heart Centre, Sunnybrook Health Sciences Centre, Toronto, Canada
| | - Peter C Austin
- ICES, Toronto, Canada.,Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Canada
| | - Douglas S Lee
- ICES, Toronto, Canada.,Peter Munk Cardiac Centre, University Health Network, Toronto, Canada.,Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Canada.,Department of Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, Canada
| |
Collapse
|
23
|
Bainey KR, Abulhamayel A, Aziz A, Becher H. Sonothrombolysis Augments Reperfusion in ST-Elevation Myocardial Infarction with Primary Percutaneous Coronary Intervention: Insights from SONOSTEMI. CJC Open 2022; 4:644-646. [PMID: 35865027 PMCID: PMC9294977 DOI: 10.1016/j.cjco.2022.03.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2022] [Accepted: 03/09/2022] [Indexed: 11/29/2022] Open
Abstract
Reperfusion injury is common following primary percutaneous coronary intervention (PCI) in ST-elevation myocardial infarction. In a prospective Canadian single-arm study of 15patients, the use of myocardial contrast echocardiography with high mechanical index ultrasound impulses (sonothrombolysis) initiated prior to primary PCI resulted in 7 patients with pre-PCI thrombolysis in myocardial infarction-2/3 flow (46.7%). Following reperfusion, all 15 patients had thrombolysis in myocardial infarction-3 flow, and 14 patients achieved ST-segment resolution ≥ 50% at 30 minutes post-PCI (93.3%). At 90 days, 12 patients had normal left ventricular ejection fraction ≥ 50% (80.0%). Our results demonstrate the feasibility of a novel technique to enhance reperfusion in ST-elevation myocardial infarction and provide a rationale for a randomized Canadian study.
Collapse
Affiliation(s)
- Kevin R. Bainey
- Canadian VIGOUR Centre, University of Alberta, Edmonton, Alberta, Canada
- Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Alberta, Canada
- Corresponding author: Dr Kevin R. Bainey, Division of Cardiology, Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Alberta, Canada. Tel.: +1-780-407-2176; fax: +1-780-407-6452.
| | - Ahmed Abulhamayel
- Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Alberta, Canada
| | - Amir Aziz
- Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Alberta, Canada
| | - Harald Becher
- Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Alberta, Canada
| |
Collapse
|
24
|
Bainey KR, Fleg JL, Hochman JS, Kunichoff DF, Anthopolos R, Chernyavskiy AM, Demkow M, Lopez-Quijano JM, Escobedo J, Poh KK, Ramos RB, Lima EG, Schuchlenz H, Ali ZA, Stone GW, Maron DJ, O'Brien SM, Spertus JA, Bangalore S. Predictors of outcome in the ISCHEMIA-CKD trial: Anatomy versus ischemia. Am Heart J 2022; 243:187-200. [PMID: 34582775 PMCID: PMC10627379 DOI: 10.1016/j.ahj.2021.09.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Accepted: 09/14/2021] [Indexed: 02/08/2023]
Abstract
BACKGROUND The ISCHEMIA-CKD (International Study of Comparative Health Effectiveness with Medical and Invasive Approaches-Chronic Kidney Disease) trial found no advantage to an invasive strategy compared to conservative management in reducing all-cause death or myocardial infarction (D/MI). However, the prognostic influence of angiographic coronary artery disease (CAD) burden and ischemia severity remains unknown in this population. We compared the relative impact of CAD extent and severity of myocardial ischemia on D/MI in patients with advanced chronic kidney disease (CKD). METHODS Participants randomized to invasive management with available data on coronary angiography and stress testing were included. Extent of CAD was defined by the number of major epicardial vessels with ≥50% diameter stenosis by quantitative coronary angiography. Ischemia severity was assessed by site investigators as moderate or severe using trial definitions. The primary endpoint was D/MI. RESULTS Of the 388 participants, 307 (79.1%) had complete coronary angiography and stress testing data. D/MI occurred in 104/307 participants (33.9%). Extent of CAD was associated with an increased risk of D/MI (P < .001), while ischemia severity was not (P = .249). These relationships persisted following multivariable adjustment. Using 0-vessel disease (VD) as reference, the adjusted hazard ratio (HR) for 1VD was 1.86, 95% confidence interval (CI) 0.94 to 3.68, P = .073; 2VD: HR 2.13, 95% CI 1.10 to 4.12, P = .025; 3VD: HR 4.00, 95% CI 2.06 to 7.76, P < .001. Using moderate ischemia as the reference, the HR for severe ischemia was 0.84, 95% CI 0.54 to 1.30, P = .427. CONCLUSION Among ISCHEMIA-CKD participants randomized to the invasive strategy, extent of CAD predicted D/MI whereas severity of ischemia did not.
Collapse
Affiliation(s)
- Kevin R Bainey
- Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Alberta, Canada.
| | - Jerome L Fleg
- National Heart Lung and Blood Institute, Bethesda, MD
| | | | | | | | - Alexander M Chernyavskiy
- E.Meshalkin National Medical Research Center of the Ministry of Health of the Russian Federation (E.Meshalkin NMRC), Novosibirsk, Russia
| | - Marcin Demkow
- Department of Coronary and Structural Heart Diseases, National Institute of Cardiology, Warsaw, Poland
| | | | - Jorge Escobedo
- Instituto Mexicano del Seguro Social, Mexico City, Mexico
| | - Kian Keong Poh
- National University Heart Center Singapore and Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | | | | | - Herwig Schuchlenz
- oLKH Graz II, Department fuer Kardiologie und Intensivmedizin, Graz, Austria
| | - Ziad A Ali
- Cardiovascular Research Foundation, New York, NY; Columbia University Medical Center/New York-Presbyterian Hospital, New York, NY; St Francis Hospital, Roslyn, NY
| | - Gregg W Stone
- Icahn School of Medicine at Mount Sinai, New York, NY
| | - David J Maron
- Stanford University School of Medicine, Stanford, CA
| | - Sean M O'Brien
- Duke Clinical Research Institute and Duke University, Durham, NC
| | - John A Spertus
- Saint Luke's Mid America Heart Institute/University of Missouri - Kansas City (UMKC), Kansas City, MO
| | | |
Collapse
|
25
|
Valle FH, Goodman SG, Tan M, Ha A, Mansour S, Welsh RC, Yan AT, Bainey KR, Rinfret S, Potter BJ, Khan R, Simkus G, Natarajan MK, Schwalm J, Daneault B, Eisenberg MJ, Abunassar J, Har B, Gregoire J, Tanguay JF, Overgaard CB, Dery JP, De Larochelliere R, Paradis JM, Madan M, Elbarouni B, So DY, Quraishi AUR, Bagai A. Antithrombotic Therapy After Percutaneous Coronary Intervention in Patients With Atrial Fibrillation: Findings From the CONNECT AF+PCI Study. CJC Open 2021; 3:1419-1427. [PMID: 34993453 PMCID: PMC8712598 DOI: 10.1016/j.cjco.2021.07.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Accepted: 07/02/2021] [Indexed: 11/29/2022] Open
Abstract
Background In patients with atrial fibrillation (AF) undergoing percutaneous coronary intervention (PCI), selecting an antithrombotic regimen requires balancing risks of ischemic cardiac events, stroke, and bleeding. Methods We studied 467 patients with AF undergoing PCI in the time period from December 2015 to July 2018 identified via a chart audit by 47 Canadian cardiologists in the CONNECT AF+PCI (the Coordinated National Network to Engage Interventional Cardiologists in the Antithrombotic Treatment of Patients With Atrial Fibrillation Undergoing Percutaneous Coronary Intervention) study, to determine patterns of initial antithrombotic therapy selection. Results The median (25th, 75th percentile) CHADS2 score was 2 (1, 3), and PCI was performed in the setting of acute coronary syndrome in 62.1%. Triple antithrombotic therapy (TAT) was the initial treatment in 62.7%, dual-pathway therapy in 25.7%, and dual antiplatelet therapy in 11.6%, with a temporal increase in use of dual-pathway therapy during the course of the study; median intended TAT duration was 1 (1, 3) month. Compared with patients selected for TAT, patients selected for dual-pathway therapy were less likely to have prior myocardial infarction (35.8% vs 25.8%, P = 0.045) and prior PCI (33.8% vs 23.3%, P = 0.03), and they received shorter total length of stents (38 [23, 56] vs 30 [20, 46] mm, P = 0.03). Patients selected for dual-pathway therapy had a higher prevalence of prior stroke/transient ischemic attack (13.0% vs 23.3%, P = 0.01). There was no difference in prevalence of anemia (21.5% vs 25.8%, P = 0.30). Use of dual-pathway therapy was similar among patients with acute coronary syndrome and those with stable disease (24.1% vs 28.2%, P = 0.32). Conclusions Approximately one-quarter of AF patients undergoing PCI are treated with dual-pathway therapy in Canadian practice, with its use increasing during the studied period. Patients selected for dual-pathway therapy have less-complex coronary disease history and intervention.
Collapse
Affiliation(s)
- Felipe H. Valle
- Terrence Donnelly Heart Centre, St Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Shaun G. Goodman
- Terrence Donnelly Heart Centre, St Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
- Canadian Heart Research Centre, Toronto, Ontario, Canada
| | - Mary Tan
- Canadian Heart Research Centre, Toronto, Ontario, Canada
| | - Andrew Ha
- University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Samer Mansour
- Centre hospitalier de l'Université de Montréal, University of Montreal, Montreal, Quebec, Canada
| | - Robert C. Welsh
- Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Alberta, Canada
| | - Andrew T. Yan
- Terrence Donnelly Heart Centre, St Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Kevin R. Bainey
- Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Alberta, Canada
| | - Stephane Rinfret
- Centre universitaire de santé McGill, McGill University, Montreal, Quebec, Canada
| | - Brian J. Potter
- Centre hospitalier de l'Université de Montréal, University of Montreal, Montreal, Quebec, Canada
| | - Razi Khan
- Royal Columbian Hospital, New Westminster, British Columbia, Canada
| | - Gerald Simkus
- Royal Columbian Hospital, New Westminster, British Columbia, Canada
| | - Madhu K. Natarajan
- Hamilton Health Sciences, Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - J.D. Schwalm
- Hamilton Health Sciences, Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - Benoit Daneault
- Centre hospitalier universitaire de Sherbrooke, Université de Sherbrooke, Sherbrooke, Quebec, Canada
| | - Mark J. Eisenberg
- Jewish General Hospital, McGill University, Montreal, Quebec, Canada
| | - Joseph Abunassar
- Kingston Health Sciences Centre, Queen’s University, Kingston, Ontario, Canada
| | - Bryan Har
- Libin Cardiovascular Institute of Alberta, University of Calgary, Calgary, Alberta, Canada
| | - Jean Gregoire
- Institut de Cardiologie de Montréal, University of Montreal, Montreal, Quebec, Canada
| | - Jean-Francois Tanguay
- Institut de Cardiologie de Montréal, University of Montreal, Montreal, Quebec, Canada
| | | | - Jean-Pierre Dery
- Institut universitaire de cardiologie et de pneumologie de Québec, Laval University, Quebec City, Quebec, Canada
| | - Robert De Larochelliere
- Institut universitaire de cardiologie et de pneumologie de Québec, Laval University, Quebec City, Quebec, Canada
| | - Jean-Michel Paradis
- Institut universitaire de cardiologie et de pneumologie de Québec, Laval University, Quebec City, Quebec, Canada
| | - Mina Madan
- Schulich Heart Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Basem Elbarouni
- St.Boniface Hospital, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Derek Y.F. So
- University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Ata-Ur-Rehman Quraishi
- Queen Elizabeth II Health Sciences Centre, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Akshay Bagai
- Terrence Donnelly Heart Centre, St Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
- Corresponding author: Dr Akshay Bagai, Terrence Donnelly Heart Centre, St Michael's Hospital, University of Toronto, 30 Bond St, Toronto, Ontario M5B1W8, Canada. Tel.: +1-416-864-5783.
| | | |
Collapse
|
26
|
Welsh R, Dover D, McMurtry MS, Bainey KR, McAlister F, Kaul P. Assessing the applicability and outcomes of the COMPASS trial a large cohort of atherosclerotic disease patients. Eur Heart J 2021. [DOI: 10.1093/eurheartj/ehab724.1217] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Abstract
Background
Atherosclerotic Cardiovascular disease (ASCVD) is the leading cause of morbidity and mortality worldwide with substantial impact on health care resources. Rivaroxaban 2.5 mg twice daily with low dose ASA reduced death, myocardial infarction and stroke compared to ASA alone in stable ASCVD patients studied in the COMPASS trial.
Purpose
To assess the applicability and potential outcomes of applying the COMPASS antithrombotic strategy in a population-based cohort of patients with ASCVD.
Methods
All patients with a new diagnosis of ASCVD identified during hospital admission or outpatient medical encounters using validated case definitions from 2008–2019 were included. We determined the proportion who met COMPASS eligibility criteria (Eligible), the proportion who met inclusion criteria but had exclusion criteria (Excluded), and the proportion who did not meet inclusion criteria (Ineligible). Primary outcomes of interest were CV death, myocardial infarction, and stroke (MACE), with secondary outcomes all cause death, CV hospitalization, PAD intervention, amputation, and all bleeding which were followed to end of study.
Results
Of 226,446 new ASCVD patients in the 11 years studied, 73% had coronary artery disease, 17% had peripheral artery disease including cerebral and peripheral vascular disease (PAD), and 10% had both. Of the 364,442 prevalent cases, 27% met COMPASS eligibility criteria, another 42% met inclusion criteria but would have been excluded and 31% were Ineligible. The main reasons for exclusion were high bleeding risk characteristics in 69% and concomitant medical therapy (CYP3A4 inducers 30%, oral anticoagulants 28%, and dual antiplatelet therapy 7%). The MACE event rates were approximately twice as high in the excluded group as those deemed COMPASS eligible (figures 1). COMPASS eligible patients in our cohort exhibited event rates similar to the ASA arm of COMPASS (figure 2). The other event rates per 100 person-years for Eligible, Excluded, and Ineligible patients respectively were: all-cause death 4.6, 10.6, 1.2,; CV hospitalization 4.8, 8.8, 3.0; PAD intervention 0.6, 0.6, 0.1; and all bleeding 1.9, 4.3, 1.1. If the COMPASS antithrombotic strategy of Rivaroxaban 2.5 twice daily with low dose ASA was given to patients deemed eligible in this population, there would have been a potential reduction of 87 MACE events, 34 CV death, 25 MI, 24 stroke, and 12 amputations per 10,000 patient years of treatment.
Conclusion
In a population of 4.4 million persons, there are approximately 20,000 incident ASCVD patients diagnosed yearly. Approximately 70% of patients with ASCVD in the real-world met COMPASS inclusion criteria, although more than half would be excluded due to high-bleed risk characteristics or concomitant medical therapy. Implementing the COMPASS antithrombotic strategy would result in substantial reduction in CV death and MACE events.
Funding Acknowledgement
Type of funding sources: Private company. Main funding source(s): Bayer MACE by COMPASS eligibilityEvent rates compared to COMPASS ASA
Collapse
Affiliation(s)
- R Welsh
- Mazankowski Alberta Heart Institute, Edmonton, Canada
| | - D Dover
- Canadian Vigour Center, Edmonton, Canada
| | | | - K R Bainey
- Mazankowski Alberta Heart Institute, Edmonton, Canada
| | | | - P Kaul
- Canadian Vigour Center, Edmonton, Canada
| |
Collapse
|
27
|
Verma S, Goodman SG, Tan MK, Daneault B, Lubelsky BJ, Mansour S, Lam AS, Laflamme D, Tymchak WJ, Welsh RC, Rose RC, Chetty RM, Constance CM, Cieza T, Potter BJ, Hartleib MC, Khan R, Choi RF, Keeble W, Dery JP, Shukla D, Chua GL, Bainey KR. Use of antithrombotic therapy for secondary prevention in patients with stable atherosclerotic cardiovascular disease: Insights from the COordinated National Network to Engage Cardiologists in the antithrombotic Treatment of patients with CardioVascular Disease (CONNECT-CVD) study. Int J Clin Pract 2021; 75:e14597. [PMID: 34228865 DOI: 10.1111/ijcp.14597] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Accepted: 07/02/2021] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Although acetylsalicylic acid is the most commonly used antithrombotic agent for the secondary prevention of cardiovascular events, residual atherothrombotic risk has prompted a guideline recommendation for the addition of dual antiplatelet therapy (DAPT) or dual pathway inhibition (DPI) in high vascular risk patients. Accordingly, the CONNECT CVD quality enhancement initiative provides a contemporary "snapshot" of the clinical features and antithrombotic management of atherosclerotic cardiovascular disease (ASCVD) patients in Canada. METHODS Canadian cardiologists (49 cardiologists from six provinces) undertook a retrospective chart audit of 10 ASCVD patients in their outpatient practice who met the Cardiovascular Outcomes for People Using Anticoagulation Strategy-like criteria from May 2018 to April 2019. RESULTS Of the 492 (two cardiologists provided 11 patients) enroled, average age was 70 years, 25% were female, 39% had diabetes and 20% had atrial fibrillation. Prior revascularisation was common (percutaneous coronary artery intervention 61%, coronary artery bypass graft 39%), with 31% having multivessel disease. A total of 47% of patients had a Reduction of Atherothrombosis for Continued Health bleeding score of ≥11 (~2.8% risk of serious bleeding at 2 years). Single antiplatelet therapy (SAPT) alone was most commonly used (62%), while 22% were on DAPT alone. In total, 22% were on oral anticoagulation (OAC), with 16% being on non-vitamin K oral anticoagulant alone, 5% on DPI and 1% received triple therapy. CONCLUSIONS In contemporary Canadian clinical practice of stable ASCVD patients, a large number of patients receive antithrombotic therapy other than SAPT. Further efforts are required to guide the appropriate selection of patients in whom more potent antithrombotic therapies may safely reduce residual risk.
Collapse
Affiliation(s)
- Sanam Verma
- Canadian VIGOUR Centre, University of Alberta, Edmonton, AB, Canada
| | - Shaun G Goodman
- Canadian VIGOUR Centre, University of Alberta, Edmonton, AB, Canada
- St Michael's Hospital, University of Toronto, Toronto, ON, Canada
- Canadian Heart Research Centre, Toronto, ON, Canada
| | - Mary K Tan
- Canadian Heart Research Centre, Toronto, ON, Canada
| | - Benoit Daneault
- Centre Hospitalier Universitaire de Sherbrooke, Université de Sherbrooke, Sherbrooke, QC, Canada
| | - Bruce J Lubelsky
- North York General Hospital, University of Toronto, Toronto, ON, Canada
| | - Samer Mansour
- Centre Hospitalier de l'Université de Montréal (CHUM) Research Center and Cardiovascular Center, Montreal, QC, Canada
| | - Andy S Lam
- West Lincoln Memorial Hospital, Grimsby, ON, Canada
| | | | | | - Robert C Welsh
- Canadian VIGOUR Centre, University of Alberta, Edmonton, AB, Canada
- Mazankowski Alberta Heart Institute, Edmonton, AB, Canada
| | - Randi C Rose
- North York General Hospital, University of Toronto, Toronto, ON, Canada
| | | | | | - Tomas Cieza
- Québec Heart and Lung Institute, Université Laval, QC, Canada
| | - Brian J Potter
- Centre Hospitalier de l'Université de Montréal (CHUM) Research Center and Cardiovascular Center, Montreal, QC, Canada
| | | | - Razi Khan
- Royal Columbian Hospital, New Westminster, BC, Canada
| | - Richard F Choi
- St Joseph's Health Centre Toronto, University of Toronto, Toronto, ON, Canada
| | - William Keeble
- Misericordia Hospital, University of Alberta, Edmonton, AB, Canada
| | | | | | | | - Kevin R Bainey
- Canadian VIGOUR Centre, University of Alberta, Edmonton, AB, Canada
- Mazankowski Alberta Heart Institute, Edmonton, AB, Canada
| |
Collapse
|
28
|
Bainey KR, Zheng Y, Coulden R, Sonnex E, Thompson R, Mei J, Bastiany A, Welsh R. Remote ischaemic conditioning in ST elevation myocardial infarction: a registry-based randomised trial. Heart 2021; 108:703-709. [PMID: 34417205 DOI: 10.1136/heartjnl-2021-319455] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Accepted: 07/29/2021] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVES Remote ischaemic conditioning (RIC) has been tested as a possible strategy for mitigating reperfusion injury in ST elevation myocardial infarction (STEMI) with primary percutaneous coronary intervention (PPCI). However, surrogate outcomes have shown inconsistent effects with lack of clinical correlation. METHODS We performed a registry-based randomised study of patients with STEMI allocated to RIC (4 cycles of blood pressure cuff inflation to 200 mm Hg for 5 min of ischaemia followed by 5 min of reperfusion) or standard of care (SOC) during PPCI. We examined the associations of RIC on core laboratory measurements of myocardial perfusion, infarct size (IS), left ventricular (LV) performance and clinical outcomes. RESULTS A total of 252 patients were enrolled. The median age was 61 (IQR: 55-70) years and 72.8% were male. Sum ST segment deviation resolution ≥50% was similar between RIC and SOC (65.2% vs 55.7%, p=0.269). In those with 3-day cardiovascular MRI (n=88), no difference in median (25th, 75th percentiles) IS (14.9% (4.5%, 23.1%) vs 16.1% (3.3%, 22.0%), p=0.980), LV dimensions (LV end-diastolic volume index: 78.7 (71.1, 91.2) mL/m2 vs 79.9 (71.2, 88.8) mL/m2, p=0.630; LV end-systolic volume index: 48.8 (35.7, 51.4) mL/m2 vs 37.9 (31.8, 47.5) mL/m2, p=0.551) or ejection fraction (50.0% (41.0%-55.0%) vs 50.0% (43.0%-56.0%), p=0.554) was demonstrated. Similar results were observed with 90-day cardiovascular MRI. At 1 year, the clinical composite of death, congestive heart failure, cardiogenic shock and recurrent myocardial infarction was similar in RIC and SOC (21.7% vs 13.3%, p=0.110). CONCLUSIONS In a contemporary registry-based randomised study of patients with STEMI undergoing PPCI, adjunctive therapy with RIC did not improve myocardial perfusion, reduce IS or alter LV performance. Consequently, there was no difference in clinical outcomes within 1 year. TRIAL REGISTRATION NUMBER NCT03930589.
Collapse
Affiliation(s)
- Kevin R Bainey
- Divison of Cardiology, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada .,Canadian VIGOUR Centre, University of Alberta, Edmonton, Alberta, Canada.,Mazankowski Alberta Heart Institute, Edmonton, Alberta, Canada
| | - Yinggan Zheng
- Canadian VIGOUR Centre, University of Alberta, Edmonton, Alberta, Canada
| | - Richard Coulden
- Divison of Cardiology, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada.,Radiology and Diagnostic Imaging, University of Alberta Hospital, Edmonton, Alberta, Canada
| | - Emer Sonnex
- Divison of Cardiology, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada.,Radiology and Diagnostic Imaging, University of Alberta Hospital, Edmonton, Alberta, Canada
| | - Richard Thompson
- Divison of Cardiology, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Junyi Mei
- Divison of Cardiology, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Alexandra Bastiany
- Divison of Cardiology, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Robert Welsh
- Divison of Cardiology, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada.,Canadian VIGOUR Centre, University of Alberta, Edmonton, Alberta, Canada.,Mazankowski Alberta Heart Institute, Edmonton, Alberta, Canada
| |
Collapse
|
29
|
Welsh RC, Shavadia JS, Zheng Y, Tyrrell BD, Leung R, Bainey KR. Ticagrelor or clopidogrel dual antiplatelet therapy following a pharmacoinvasive strategy in ST-segment elevation myocardial infarction. Clin Cardiol 2021; 44:1543-1550. [PMID: 34405422 PMCID: PMC8571547 DOI: 10.1002/clc.23716] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Revised: 07/27/2021] [Accepted: 08/05/2021] [Indexed: 01/30/2023] Open
Abstract
Objectives To describe and evaluate outcomes in STEMI patients sustained on clopidogrel compared to those switched to ticagrelor following fibrinolysis. Background World‐wide, many STEMI patients cannot achieve timely PCI and therefore require fibrinolysis. Although comparable 30‐day and 1‐year safety was shown with clopidogrel or ticagrelor in the TREAT study, there is paucity of long‐term outcomes in pharmacoinvasive treated STEMI. Methods We conducted an observational cohort study evaluating consecutive pharmacoinvasive STEMI patients treated in a network, comparing those switched to ticagrelor to those sustained on clopidogrel. The primary efficacy composite was one‐year all‐cause death, recurrent myocardial infarction, and stroke with major bleeding and intracranial hemorrhage (ICH) as the safety outcomes. Multivariable Cox regression model was used to examine the association between P2Y12 inhibitor and outcomes with inverse probability weighting. Results Of 1426 pharmacoinvasive STEMI patients, 28% (n = 396) were converted to ticagrelor at a mean of 9.9 h after fibrinolysis with comparable GRACE Risk Scores (median; 158 vs 157, p0.352). The primary composite occurred in 3.5% of ticagrelor and 7.0% of clopidogrel treated patients (p0.014). Following adjustment, ticagrelor was associated with a 54% lower composite outcome (adjusted HR 0.46, 95% confidence interval 0.26–0.84). Major bleeding 6.3% vs 6.1% (NS) and ICH 0.0% vs 0.2% (NS) were similar. Conclusions In a prospective STEMI cohort, switching to ticagrelor compared with sustaining clopidogrel following fibrinolysis pharmacoinvasive reperfusion reduced recurrent ischemic events at 1‐year with no differences in major bleeding or ICH. Aligned with randomized data, these findings provide support to switch pharmaco‐invasively treated STEMI patients.
Collapse
Affiliation(s)
- Robert C Welsh
- Canadian VIGOUR Centre, University of Alberta, Edmonton, Alberta, Canada.,Division of Cardiology, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada.,Cardiac Sciences, Mazankowski Alberta Heart Institute, Edmonton, Alberta, Canada
| | - Jay S Shavadia
- Canadian VIGOUR Centre, University of Alberta, Edmonton, Alberta, Canada.,Division of Cardiology, Department of Medicine, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Yinggan Zheng
- Canadian VIGOUR Centre, University of Alberta, Edmonton, Alberta, Canada.,Division of Cardiology, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada.,Cardiac Sciences, Mazankowski Alberta Heart Institute, Edmonton, Alberta, Canada
| | | | - Raymond Leung
- Cardiology, CK Hui Heart Centre, Edmonton, Alberta, Canada
| | - Kevin R Bainey
- Canadian VIGOUR Centre, University of Alberta, Edmonton, Alberta, Canada.,Division of Cardiology, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada.,Cardiac Sciences, Mazankowski Alberta Heart Institute, Edmonton, Alberta, Canada
| |
Collapse
|
30
|
Khan R, Kaul P, Islam S, Savu A, Bagai A, van Diepen S, Bainey KR, Welsh RC, Goodman SG. Drug Adherence and Long-Term Outcomes in Non-Revascularized Patients Following Acute Myocardial Infarction. Am J Cardiol 2021; 152:49-56. [PMID: 34120704 DOI: 10.1016/j.amjcard.2021.04.031] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2021] [Revised: 04/09/2021] [Accepted: 04/13/2021] [Indexed: 12/29/2022]
Abstract
This study examined long-term outcomes and adherence to guideline-based medications in non-revascularized acute myocardial infarction (MI) patients undergoing and not undergoing angiography. We analyzed non-revascularized MI patients hospitalized in Alberta, Canada between 2010-2016 and categorized them according to whether they had undergone coronary angiography. Adherence to guideline-based medications was determined by the proportion of days covered (PDC) and subdivided into categories based on PDC: 0% (none), 1-40% (low), 40-79% (intermediate) and ≥ 80% (high). Patients not undergoing angiography were older, less frequently male, and had more comorbidities. Those not receiving angiography had higher rates of 2-year myocardial infarction (9.9% vs 6.1%, p <0.001), heart failure (14.9% vs 6.1%, p <0.001), and mortality (29.4% vs 7.4%, p <0.001). Optimal medial therapy (OMT), defined by high PDC for the combination of lipid-modifying agents, β-blockers and angiotensin converting enzyme-inhibitors/receptor blockers (ACE-I/ARBs), was achieved in 32.9%. Patients not undergoing angiography had lower rates of OMT adherence (p <0.001). In patients not undergoing angiography, high-adherence to lipid-modifying agents (HR 0.70 [95% CI 0.57-0.87]), β-blockers (HR 0.78 [0.62-0.97]), ACE-I/ARBs (HR 0.64 [0.52-0.79]) and OMT (HR 0.56 [0.40-0.77]) was independently associated with lower 2-year mortality. In conclusion, MI patients not receiving angiography had low adherence rates to guideline-based pharmacotherapies and high rates of long-term outcomes, suggesting potential treatment targets to improve prognosis in non-invasively managed MI patients.
Collapse
|
31
|
Dehghani P, Cantor WJ, Wang J, Wood DA, Storey RF, Mehran R, Bainey KR, Welsh RC, Rodés-Cabau J, Rao S, Lavi S, Velianou JL, Natarajan MK, Ziakas A, Guiducci V, Fernández-Avilés F, Cairns JA, Mehta SR. Complete Revascularization in Patients Undergoing a Pharmacoinvasive Strategy for ST-Segment-Elevation Myocardial Infarction: Insights From the COMPLETE Trial. Circ Cardiovasc Interv 2021; 14:e010458. [PMID: 34320839 DOI: 10.1161/circinterventions.120.010458] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
[Figure: see text].
Collapse
Affiliation(s)
- Payam Dehghani
- Prairie Vascular Research Network, University of Saskatchewan, Regina, Canada (P.D.)
| | - Warren J Cantor
- Toronto Southlake Regional Health Centre, University of Toronto, Ontario, Canada (W.J.C.)
| | - Jia Wang
- Hamilton Health Sciences, McMaster University, Ontario, Canada (J.W., J.L.V., M.K.N., S.R.M.)
- Population Health Research Institute, Hamilton, Ontario, Canada (J.W., M.K.N., S.R.M.)
| | - David A Wood
- Centre for Cardiovascular Innovation, St. Paul's and Vancouver General Hospitals, University of British Columbia, Canada (D.A.W., J.A.C.)
| | - Robert F Storey
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, United Kingdom (R.F.S.)
| | - Roxana Mehran
- The Zena A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY (R.M.)
| | - Kevin R Bainey
- Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Canada (K.R.B., R.C.W.)
| | - Robert C Welsh
- Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Canada (K.R.B., R.C.W.)
| | - Josep Rodés-Cabau
- Institut Universitaire de Cardiologie et de Pneumologie de Québec, Canada (J.R.-C.)
| | - Sunil Rao
- Duke University Medical Center, Durham, NC (S.R.)
| | - Shahar Lavi
- London Health Sciences Centre, University of Western Ontario, Canada (S.L.)
| | - James L Velianou
- Hamilton Health Sciences, McMaster University, Ontario, Canada (J.W., J.L.V., M.K.N., S.R.M.)
| | - Madhu K Natarajan
- Hamilton Health Sciences, McMaster University, Ontario, Canada (J.W., J.L.V., M.K.N., S.R.M.)
- Population Health Research Institute, Hamilton, Ontario, Canada (J.W., M.K.N., S.R.M.)
| | - Antonios Ziakas
- AHEPA University Hospital, Aristotle University of Thessaloniki, Greece (A.Z.)
| | | | | | - John A Cairns
- Centre for Cardiovascular Innovation, St. Paul's and Vancouver General Hospitals, University of British Columbia, Canada (D.A.W., J.A.C.)
| | - Shamir R Mehta
- Hamilton Health Sciences, McMaster University, Ontario, Canada (J.W., J.L.V., M.K.N., S.R.M.)
- Population Health Research Institute, Hamilton, Ontario, Canada (J.W., M.K.N., S.R.M.)
| |
Collapse
|
32
|
Sunner SS, Welsh RC, Bainey KR. Medical Management of Peripheral Arterial Disease: Deciphering the Intricacies of Therapeutic Options. CJC Open 2021; 3:936-949. [PMID: 34401701 PMCID: PMC8348339 DOI: 10.1016/j.cjco.2021.03.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Accepted: 03/08/2021] [Indexed: 01/01/2023] Open
Abstract
Due to the pathophysiology of atherosclerosis, the management for coronary artery disease and peripheral arterial disease (PAD) were considered homogenous, with therapies focused on the use of lipid-lowering medications, antiplatelet therapy, glucose control, and blood pressure management. However, more recently, studies have supported the use of tailored therapeutics and medical targets for patients with PAD that sometimes differ from those for coronary artery disease. Moreover, we are now witnessing large randomized PAD-specific trials that have altered therapeutic regimens and targets. Given these updates, dissemination of knowledge is lacking, as evidenced by discordant guideline recommendations. This comprehensive review provides an overview of contemporary therapeutic options for secondary prevention for patients with PAD.
Collapse
Affiliation(s)
- Sanjot S. Sunner
- Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Alberta, Canada
| | - Robert C. Welsh
- Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Alberta, Canada
- Canadian VIGOUR Centre, University of Alberta, Edmonton, Alberta, Canada
| | - Kevin R. Bainey
- Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Alberta, Canada
- Canadian VIGOUR Centre, University of Alberta, Edmonton, Alberta, Canada
| |
Collapse
|
33
|
Gouda P, Savu A, Bainey KR, Kaul P, Welsh RC. Long-term risk of death and recurrent cardiovascular events following acute coronary syndromes. PLoS One 2021; 16:e0254008. [PMID: 34197547 PMCID: PMC8248628 DOI: 10.1371/journal.pone.0254008] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Accepted: 06/18/2021] [Indexed: 11/29/2022] Open
Abstract
Estimates of the risk of recurrent cardiovascular events (residual risk) among patients with acute coronary syndromes have largely been based on clinical trial populations. Our objective was to estimate the residual risk associated with common comorbidities in a large, unselected, population-based cohort of acute coronary syndrome patients. 31,056 ACS patients (49.5%—non-ST segment elevation myocardial infarction [NSTEMI], 34.0%—ST segment elevation myocardial infarction [STEMI] and 16.5%—unstable angina [UA]) hospitalised in Alberta between April 2010 and March 2016 were included. The primary composite outcome was major adverse cardiovascular events (MACE) including: death, stroke or recurrent myocardial infarction. The secondary outcome was death from any cause. Cox-proportional hazard models were used to identify the impact of ACS type and commonly observed comorbidities (heart failure, hypertension, peripheral vascular disease, renal disease, cerebrovascular disease and diabetes). At 3.0 +/- 3.7 years, rates of MACE were highest in the NSTEMI population followed by STEMI and UA (3.58, 2.41 and 1.68 per 10,000 person years respectively). Mortality was also highest in the NSTEMI population followed by STEMI and UA (2.23, 1.38 and 0.95 per 10,000 person years respectively). Increased burden of comorbidities was associated with an increased risk of MACE, most prominently seen with heart failure (adjusted HR 1.83; 95% CI 1.73–1.93), renal disease (adjusted HR 1.52; 95% CI 1.40–1.65) and diabetes (adjusted HR 1.51; 95% CI 1.44–1.59). The cumulative presence of each of examined comorbidities was associated with an incremental increase in the rate of MACE ranging from 1.7 to 9.98 per 10,000 person years. Rates of secondary prevention medications at discharge were high including: statin (89.5%), angiotensin converting enzyme inhibitor/angiotensin receptor blocker (84.1%) and beta-blockers (85.9%). Residual cardiovascular risk following an acute coronary syndrome remains high despite advances in secondary prevention. A higher burden of comorbidities is associated with increased residual risk that may benefit from aggressive or novel therapies.
Collapse
Affiliation(s)
- Pishoy Gouda
- Division of Cardiology, Department of Medicine, Mazankowksi Alberta Heart Institute and University of Alberta, Edmonton, Alberta, Canada
| | - Anamaria Savu
- Canadian VIGOUR Centre, University of Alberta, Edmonton, Alberta, Canada
| | - Kevin R. Bainey
- Division of Cardiology, Department of Medicine, Mazankowksi Alberta Heart Institute and University of Alberta, Edmonton, Alberta, Canada
- Canadian VIGOUR Centre, University of Alberta, Edmonton, Alberta, Canada
| | - Padma Kaul
- Division of Cardiology, Department of Medicine, Mazankowksi Alberta Heart Institute and University of Alberta, Edmonton, Alberta, Canada
- Canadian VIGOUR Centre, University of Alberta, Edmonton, Alberta, Canada
- Canadian Institutes of Health Research Chair in Sex and Gender Science, Edmonton, Alberta, Canada
| | - Robert C. Welsh
- Division of Cardiology, Department of Medicine, Mazankowksi Alberta Heart Institute and University of Alberta, Edmonton, Alberta, Canada
- Canadian VIGOUR Centre, University of Alberta, Edmonton, Alberta, Canada
- * E-mail:
| |
Collapse
|
34
|
Das D, Savu A, Bainey KR, Welsh RC, Kaul P. Temporal Trends in in-Hospital Bleeding and Transfusion in a Contemporary Canadian ST-Elevation Myocardial Infarction Patient Population. CJC Open 2021; 3:479-487. [PMID: 34027351 PMCID: PMC8129449 DOI: 10.1016/j.cjco.2020.12.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2020] [Accepted: 12/05/2020] [Indexed: 02/06/2023] Open
Abstract
Background Although ST-elevation myocardial infarction (STEMI) management has evolved substantially over the past decade, its effect on bleeding and transfusion rates are largely unknown in a contemporary population. Methods Our study cohort included patients 20 years of age or older who were hospitalized for STEMI between 2007 and 2016 across all Canadian provinces, except Quebec. Unadjusted rates of bleeding and of transfusion during STEMI episodes were calculated overall and for each province according to fiscal year. Patients were stratified into 4 groups according to their bleeding/transfusion. Characteristics, treatment, and outcomes were compared between groups. Multivariate logistic regression modelling was used to assess the association between bleeding and transfusion on in-hospital mortality. Results Using 108,832 STEMI episodes, rates of in-hospital bleeding and transfusion declined between 2007 and 2016 from 3.9% to 2.8% (P < 0.0001) and 4.7% to 3.8% (P < 0.0001), respectively. However, variation in bleeding and transfusion rates were observed across Canadian provinces. Patients with bleeding or transfusion, were older, female, and had more comorbidities. Compared with patients who did not bleed or receive a transfusion, individuals who bled, were transfused, or bled and were transfused, had higher in-hospital mortality (18.6%, 30.3%, and 30.4%, respectively [P < 0.0001]). The association remained after adjustment: bleeding (odds ratio [OR], 2.0; 95% confidence interval [CI], 1.8-2.4), transfusion (OR, 4.4; 95% CI, 3.9-4.9), and bleeding and transfusion (OR, 3.8; 95% CI, 3.2-4.6). Conclusions The proportion of Canadian STEMI patients who experienced in-hospital bleeding and transfusion has decreased over the past 9 years. However, patients with bleed or transfusion remain at higher risk of adverse outcomes.
Collapse
Affiliation(s)
- Debraj Das
- Division of Cardiology, University of Alberta, Edmonton, Alberta, Canada
| | - Anamaria Savu
- Canadian VIGOUR Centre, University of Alberta, Edmonton, Alberta, Canada
| | - Kevin R Bainey
- Division of Cardiology, University of Alberta, Edmonton, Alberta, Canada.,Canadian VIGOUR Centre, University of Alberta, Edmonton, Alberta, Canada
| | - Robert C Welsh
- Division of Cardiology, University of Alberta, Edmonton, Alberta, Canada.,Canadian VIGOUR Centre, University of Alberta, Edmonton, Alberta, Canada
| | - Padma Kaul
- Division of Cardiology, University of Alberta, Edmonton, Alberta, Canada.,Canadian VIGOUR Centre, University of Alberta, Edmonton, Alberta, Canada
| |
Collapse
|
35
|
Rinfret S, Jahan I, McKenzie K, Dendukuri N, Bainey KR, Mansour S, Natarajan M, Ybarra LF, Chong AY, Bérubé S, Breton R, Curtis MJ, Rodés-Cabau J, Amlani S, Bagherli A, Ball W, Barolet A, Beydoun HK, Brass N, Chan AW, Colizza F, Constance C, Fam NP, Gobeil F, Haghighat T, Hodge S, Joyal D, Kim HH, Lutchmedial S, MacDougall A, Malik P, Miner S, Minhas K, Orvold J, Palisaitis D, Parfrey B, Potvin JM, Puley G, Radhakrishnan S, Spaziano M, Tanguay JF, Vijayaraghaban R, Webb JG, Zimmermann RH, Wood DA, Brophy JM. COVID-19 pandemic and coronary angiography for ST-elevation myocardial infarction, use of mechanical support and mechanical complications in Canada; a Canadian Association of Interventional Cardiology national survey. CJC Open 2021; 3:1125-1131. [PMID: 33997751 PMCID: PMC8114614 DOI: 10.1016/j.cjco.2021.04.017] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Accepted: 04/12/2021] [Indexed: 11/15/2022] Open
Abstract
Background As a result of the COVID-19 pandemic first wave, reductions in ST-elevation myocardial infarction (STEMI) invasive care, ranging from 23% to 76%, have been reported from various countries. Whether this change had any impact on coronary angiography (CA) volume or on mechanical support device use for STEMI and post-STEMI mechanical complications in Canada is unknown. Methods We administered a Canada-wide survey to all cardiac catheterization laboratory directors, seeking the volume of CA use for STEMI performed during the period from March 1 2020 to May 31, 2020 (pandemic period), and during 2 control periods (March 1, 2019 to May 31, 2019 and March 1, 2018 to May 31, 2018). The number of left ventricular support devices used, as well as the number of ventricular septal defects and papillary muscle rupture cases diagnosed, was also recorded. We also assessed whether the number of COVID-19 cases recorded in each province was associated with STEMI-related CA volume. Results A total of 41 of 42 Canadian catheterization laboratories (98%) provided data. There was a modest but statistically significant 16% reduction (incidence rate ratio [IRR] 0.84; 95% confidence interval 0.80-0.87) in CA for STEMI during the first wave of the pandemic, compared to control periods. IRR was not associated with provincial COVID-19 caseload. We observed a 26% reduction (IRR 0.74; 95% confidence interval 0.61-0.89) in the use of intra-aortic balloon pump use for STEMI. Use of an Impella pump and mechanical complications from STEMI were exceedingly rare. Conclusions We observed a modest 16% decrease in use of CA for STEMI during the pandemic first wave in Canada, lower than the level reported in other countries. Provincial COVID-19 caseload did not influence this reduction.
Collapse
Affiliation(s)
- Stéphane Rinfret
- Division of Cardiology, McGill University Health Centre, McGill University, Montreal, QC
| | - Israth Jahan
- Department of medicine and biostatistics, McGill University Health Centre, McGill University, Montreal, QC
| | | | - Nandini Dendukuri
- Department of medicine and biostatistics, McGill University Health Centre, McGill University, Montreal, QC
| | - Kevin R Bainey
- Division of cardiology, Mazankowski Alberta Heart Institute, Edmonton, AB
| | - Samer Mansour
- Division of cardiology, Centre Hospitalier de l'Université de Montréal, Montreal, QC.,Division of cardiology, Hôpital de la Cité-de-la-Santé, Laval, QC
| | - Madhu Natarajan
- Division of cardiology, Hamilton Health Sciences Centre, Hamilton, ON
| | - Luiz F Ybarra
- Division of cardiology, London Health Sciences Centre, London, ON
| | - Aun-Yeong Chong
- Division of cardiology, University of Ottawa Heart Institute, Ottawa, ON
| | - Simon Bérubé
- Division of cardiology, CIUSSS de l'Estrie - CHUS, Sherbrooke, QC
| | - Robert Breton
- Division of cardiology, CIUSSS Saguenay Lac Saint Jean, Saguenay, QC
| | | | - Josep Rodés-Cabau
- Multidisciplinary department of cardiology, Institut universitaire de cardiologie et de pneumologie de Québec-Hôpital Laval, Quebec City, QC
| | - Shy Amlani
- Division of cardiology, William Osler Health System, Brampton, ON
| | | | - Warren Ball
- Division of cardiology, Peterborough Regional Health Centre, Peterborough, ON
| | - Alan Barolet
- Division of cardiology, University Health Network - Toronto General Hospital, Toronto, ON
| | | | - Neil Brass
- Division of cardiology, CK Hui Heart Centre/Royal Alexandra Hospital, Edmonton, AB
| | - Albert W Chan
- Division of cardiology, Royal Columbian Hospital, New Westminster, BC
| | - Franco Colizza
- Division of cardiology, Centre Hospitalier Pierre-Boucher, Longueuil, QC
| | | | - Neil P Fam
- Division of cardiology, St. Michael's Hospital, Montreal, QC
| | - François Gobeil
- Division of cardiology, Centre Hospitalier de l'Université de Montréal, Montreal, QC
| | | | - Steven Hodge
- Division of cardiology, Kelowna General Hospital, Kelowna, BC
| | - Dominique Joyal
- Division of cardiology, Jewish General Hospital, Montreal, QC
| | - Hahn Hoe Kim
- Division of cardiology, St-Mary's Regional Cardiac Care Centre, Kitchener-Waterloo, ON
| | | | - Andrea MacDougall
- Division of cardiology, Thunder Bay Regional Health Sciences Centre, Thunder Bay, ON
| | - Paul Malik
- Division of cardiology, Kingston General Hospital, Kingston, ON
| | - Steve Miner
- Division of cardiology, Southlake Regional Health Centre, Newmarket, ON
| | - Kunal Minhas
- Division of cardiology, St. Boniface General Hospital, Winnipeg, MB
| | - Jason Orvold
- Division of cardiology, Royal University Hospital, Saskatoon, SK
| | | | - Brendan Parfrey
- Division of cardiology, Health Sciences Center, St-John's, NF
| | | | - Geoffrey Puley
- Division of cardiology, Trillium Health Centre, Mississauga, ON
| | - Sam Radhakrishnan
- Division of cardiology, Sunnybrook Health Sciences Centre, Toronto, ON
| | - Marco Spaziano
- Division of Cardiology, McGill University Health Centre, McGill University, Montreal, QC
| | | | | | - John G Webb
- Division of cardiology, St. Paul's Hospital, Vancouver BC
| | | | - David A Wood
- Division of cardiology, Vancouver General Hospital, Vancouver, BC
| | - James M Brophy
- Division of Cardiology, McGill University Health Centre, McGill University, Montreal, QC
| |
Collapse
|
36
|
Moxham R, Džavík V, Cairns J, Natarajan MK, Bainey KR, Akl E, Tsang MB, Lavi S, Cantor WJ, Madan M, Liu YY, Jolly SS. Association of Thrombus Aspiration With Time and Mortality Among Patients With ST-Segment Elevation Myocardial Infarction: A Post Hoc Analysis of the Randomized TOTAL Trial. JAMA Netw Open 2021; 4:e213505. [PMID: 33769510 PMCID: PMC7998077 DOI: 10.1001/jamanetworkopen.2021.3505] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
IMPORTANCE Patients with shorter ischemic times have a greater viable myocardium and may derive greater benefit from thrombus aspiration. OBJECTIVE To study the association of thrombus aspiration with outcomes among patients presenting with ST-segment elevation myocardial infarction (STEMI) based on time. DESIGN, SETTING, AND PARTICIPANTS The TOTAL (Thrombectomy With PCI vs PCI Alone in Patients with STEMI) trial was an international randomized clinical trial of 10 732 patients with STEMI undergoing primary percutaneous coronary intervention (PCI) within 12 hours of symptom onset. Patients were recruited between August 5, 2010, and July 25, 2014, and were followed up for 1 year. Data analysis was performed from February 22, 2019, to January 5, 2021. INTERVENTIONS Thrombus aspiration vs PCI alone. MAIN OUTCOMES AND MEASURES Post hoc subgroup analyses were performed for total ischemic time and first medical contact (FMC)-to-device time for the primary outcomes (cardiovascular [CV] mortality, myocardial Infarction [MI], cardiogenic shock, and New York Heart Association class IV heart failure) and angiographically determined distal embolization. In addition, a multivariable analysis was performed to assess the association of total ischemic time and FMC-to-device time with CV mortality at 1 year. RESULTS The study randomized 10 732 patients, and 9986 underwent primary PCI and had time data available (7737 men [77.5%]; mean [SD] age, 61.0 [12.0] years). For the randomized comparison of thrombus aspiration, there was a reduction in angiographic distal embolization with thrombus aspiration that was more pronounced in patients with short ischemic times (<2 hours: odds ratio [OR], 0.23 [95% CI, 0.09-0.62]; 2-6 hours: OR, 0.54 [95% CI, 0.39-0.73]; >6 hours: OR, 0.70 [95% CI, 0.33-1.50]; P = .12 for interaction). However, for the primary composite outcome, there was no benefit based on (1) total ischemic time (<2 hours: hazard ratio [HR], 0.77 [95% CI, 0.46-1.28]; 2-6 hours: HR, 1.03 [95% CI, 0.85-1.25]; >6 hours: HR, 0.87 [95% CI, 0.60-1.27]; P = .46 for interaction) or (2) FMC-to-device time (<60 minutes: HR, 1.14 [95% CI, 0.66-1.95]; 60-90 minutes: HR, 0.94 [95% CI, 0.67-1.32]; >90-120 minutes: HR, 1.19 [95% CI, 0.85-1.67]; >120 minutes: HR, 0.89 [95% CI, 0.70-1.14]; P = .54 for interaction). In a multivariable analysis, both total ischemic time (>2 hours: HR, 1.26 [95% CI, 1.00-1.58) and FMC-to-device time (>120 minutes: HR, 1.45 [95% CI, 1.18-1.79]) were independently associated with CV mortality. CONCLUSIONS AND RELEVANCE This analysis suggests that thrombus aspiration does not appear to be associated with an improvement in clinical outcomes regardless of ischemic time. In the current STEMI era, both total ischemic time and FMC-to-device times continue to be important factors associated with mortality. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT01149044.
Collapse
Affiliation(s)
- Rachel Moxham
- McMaster University and Population Health Research Institute, Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - Vladimír Džavík
- Peter Munk Cardiac Centre, University Health Network, Toronto, Ontario, Canada
| | - John Cairns
- Division of Cardiology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Madhu K. Natarajan
- McMaster University and Population Health Research Institute, Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - Kevin R. Bainey
- Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Alberta, Canada
| | - Elie Akl
- McGill University Health Centre, Montreal, Quebec, Canada
| | - Michael B. Tsang
- McMaster University and Population Health Research Institute, Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - Shahar Lavi
- London Health Sciences Centre, Western University, London, Ontario, Canada
| | - Warren J. Cantor
- Southlake Regional Health Center, University of Toronto, Toronto, Ontario, Canada
| | - Mina Madan
- Schulich Heart Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Yan Yun Liu
- McMaster University and Population Health Research Institute, Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - Sanjit S. Jolly
- McMaster University and Population Health Research Institute, Hamilton Health Sciences, Hamilton, Ontario, Canada
| |
Collapse
|
37
|
Bainey KR. DAPT risk stratification using coronary artery angioscopy at 2 weeks: Personalized medicine at its finest? Atherosclerosis 2021; 322:74-76. [PMID: 33637291 DOI: 10.1016/j.atherosclerosis.2021.02.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2021] [Revised: 02/09/2021] [Accepted: 02/12/2021] [Indexed: 11/17/2022]
|
38
|
Reynolds HR, Maehara A, Kwong RY, Sedlak T, Saw J, Smilowitz NR, Mahmud E, Wei J, Marzo K, Matsumura M, Seno A, Hausvater A, Giesler C, Jhalani N, Toma C, Har B, Thomas D, Mehta LS, Trost J, Mehta PK, Ahmed B, Bainey KR, Xia Y, Shah B, Attubato M, Bangalore S, Razzouk L, Ali ZA, Merz NB, Park K, Hada E, Zhong H, Hochman JS. Coronary Optical Coherence Tomography and Cardiac Magnetic Resonance Imaging to Determine Underlying Causes of Myocardial Infarction With Nonobstructive Coronary Arteries in Women. Circulation 2021; 143:624-640. [PMID: 33191769 PMCID: PMC8627695 DOI: 10.1161/circulationaha.120.052008] [Citation(s) in RCA: 169] [Impact Index Per Article: 56.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND Myocardial infarction with nonobstructive coronary arteries (MINOCA) occurs in 6% to 15% of myocardial infarctions (MIs) and disproportionately affects women. Scientific statements recommend multimodality imaging in MINOCA to define the underlying cause. We performed coronary optical coherence tomography (OCT) and cardiac magnetic resonance (CMR) imaging to assess mechanisms of MINOCA. METHODS In this prospective, multicenter, international, observational study, we enrolled women with a clinical diagnosis of myocardial infarction. If invasive coronary angiography revealed <50% stenosis in all major arteries, multivessel OCT was performed, followed by CMR (cine imaging, late gadolinium enhancement, and T2-weighted imaging and T1 mapping). Angiography, OCT, and CMR were evaluated at blinded, independent core laboratories. Culprit lesions identified by OCT were classified as definite or possible. The CMR core laboratory identified ischemia-related and nonischemic myocardial injury. Imaging results were combined to determine the mechanism of MINOCA, when possible. RESULTS Among 301 women enrolled at 16 sites, 170 were diagnosed with MINOCA, of whom 145 had adequate OCT image quality for analysis; 116 of these underwent CMR. A definite or possible culprit lesion was identified by OCT in 46.2% (67/145) of participants, most commonly plaque rupture, intraplaque cavity, or layered plaque. CMR was abnormal in 74.1% (86/116) of participants. An ischemic pattern of CMR abnormalities (infarction or myocardial edema in a coronary territory) was present in 53.4% (62/116) of participants undergoing CMR. A nonischemic pattern of CMR abnormalities (myocarditis, takotsubo syndrome, or nonischemic cardiomyopathy) was present in 20.7% (24/116). A cause of MINOCA was identified in 84.5% (98/116) of the women with multimodality imaging, higher than with OCT alone (P<0.001) or CMR alone (P=0.001). An ischemic cause was identified in 63.8% of women with MINOCA (74/116), a nonischemic cause was identified in 20.7% (24/116) of the women, and no mechanism was identified in 15.5% (18/116). CONCLUSIONS Multimodality imaging with coronary OCT and CMR identified potential mechanisms in 84.5% of women with a diagnosis of MINOCA, 75.5% of which were ischemic and 24.5% of which were nonischemic, alternate diagnoses to myocardial infarction. Identification of the cause of MINOCA is feasible and has the potential to guide medical therapy for secondary prevention. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT02905357.
Collapse
Affiliation(s)
- Harmony R. Reynolds
- Sarah Ross Soter Center for Women’s Cardiovascular Research, New York University Grossman School of Medicine, NY,Leon H. Charney Division of Cardiology, Department of Medicine, New York University Grossman School of Medicine, NY
| | - Akiko Maehara
- Cardiovascular Research Foundation, New York, NY,Columbia University, New York, NY
| | | | - Tara Sedlak
- Vancouver General Hospital, British Columbia, Canada
| | | | - Nathaniel R. Smilowitz
- Sarah Ross Soter Center for Women’s Cardiovascular Research, New York University Grossman School of Medicine, NY,Leon H. Charney Division of Cardiology, Department of Medicine, New York University Grossman School of Medicine, NY
| | | | - Janet Wei
- Barbra Streisand Women’s Heart Center, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Kevin Marzo
- New York University Winthrop Hospital, New York University Long Island School of Medicine, Mineola
| | | | - Ayako Seno
- Brigham and Women’s Hospital, Boston, MA
| | - Anais Hausvater
- Sarah Ross Soter Center for Women’s Cardiovascular Research, New York University Grossman School of Medicine, NY,Leon H. Charney Division of Cardiology, Department of Medicine, New York University Grossman School of Medicine, NY
| | | | | | - Catalin Toma
- University of Pittsburgh Department of Medicine, PA
| | - Bryan Har
- University of Calgary, Alberta, Canada
| | | | | | | | | | - Bina Ahmed
- Santa Barbara Cardiovascular Medical Group, CA
| | - Kevin R. Bainey
- Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Canada
| | - Yuhe Xia
- Department of Population Health, New York University Grossman School of Medicine, NY
| | - Binita Shah
- Leon H. Charney Division of Cardiology, Department of Medicine, New York University Grossman School of Medicine, NY
| | - Michael Attubato
- Leon H. Charney Division of Cardiology, Department of Medicine, New York University Grossman School of Medicine, NY
| | - Sripal Bangalore
- Leon H. Charney Division of Cardiology, Department of Medicine, New York University Grossman School of Medicine, NY
| | - Louai Razzouk
- Leon H. Charney Division of Cardiology, Department of Medicine, New York University Grossman School of Medicine, NY
| | - Ziad A. Ali
- Cardiovascular Research Foundation, New York, NY,Columbia University, New York, NY
| | - Noel Bairey Merz
- Barbra Streisand Women’s Heart Center, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Ki Park
- University of Florida, Gainesville
| | - Ellen Hada
- Sarah Ross Soter Center for Women’s Cardiovascular Research, New York University Grossman School of Medicine, NY
| | - Hua Zhong
- Department of Population Health, New York University Grossman School of Medicine, NY
| | - Judith S. Hochman
- Sarah Ross Soter Center for Women’s Cardiovascular Research, New York University Grossman School of Medicine, NY,Leon H. Charney Division of Cardiology, Department of Medicine, New York University Grossman School of Medicine, NY
| |
Collapse
|
39
|
Alyamani M, Campbell S, Navarese E, Welsh RC, Bainey KR. Safety and Efficacy of Intracoronary Thrombolysis as Adjunctive Therapy to Primary PCI in STEMI: A Systematic Review and Meta-analysis. Can J Cardiol 2021; 37:339-346. [DOI: 10.1016/j.cjca.2020.03.034] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2019] [Revised: 03/05/2020] [Accepted: 03/22/2020] [Indexed: 12/19/2022] Open
|
40
|
Bainey KR, Alemayehu W, Welsh RC, Kumar A, King SB, Kirtane AJ. Long-Term Clinical Outcomes Following Revascularization in High-Risk Coronary Anatomy Patients With Stable Ischemic Heart Disease. J Am Heart Assoc 2020; 10:e018104. [PMID: 33342230 PMCID: PMC7955498 DOI: 10.1161/jaha.120.018104] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Background The ISCHEMIA (International Study of Comparative Health Effectiveness with Medical and Invasive Approaches) trial failed to show a reduction in hard clinical end points with an early invasive strategy in stable ischemic heart disease (SIHD). However, the influence of left main disease and high-risk coronary anatomy was left unaddressed. In a large angiographic disease-based registry, we examined the modulating effect of revascularization on long-term outcomes in anatomically high-risk SIHD. Methods and Results 9016 patients with SIHD with high-risk coronary anatomy (3 vessel disease with ≥70% stenosis in all 3 epicardial vessels or left main disease ≥50% stenosis [isolated or in combination with other disease]) were selected for study from April 1, 2002 to March 31, 2016. The primary composite of all-cause death or myocardial infarction (MI) was compared between revascularization versus conservative management. A total of 5487 (61.0%) patients received revascularization with either coronary artery bypass graft surgery (n=3312) or percutaneous coronary intervention (n=2175), while 3529 (39.0%) patients were managed conservatively. Selection for coronary revascularization was associated with improved all-cause death/MI as well as longer survival compared with selection for conservative management (Inverse Probability Weighted hazard ratio [IPW-HR] 0.62; 95% CI 0.58 to 0.66; P<0.001; IPW-HR 0.57; 95% CI 0.53-0.61; P<0.001, respectively). Similar risk reduction was noted with percutaneous coronary intervention (IPW-HR 0.64, 95% CI 0.59-0.70, P<0.001) and coronary artery bypass graft surgery (IPW-HR 0.61; 95% CI 0.57-0.66; P<0.001). Conclusions Revascularization in patients with SIHD with high-risk coronary anatomy was associated with improved long-term outcome compared with conservative therapy. As such, coronary anatomical profile should be considered when contemplating treatment for SIHD.
Collapse
Affiliation(s)
- Kevin R Bainey
- Canadian VIGOUR Center University of Alberta Edmonton Alberta Canada
| | | | - Robert C Welsh
- Canadian VIGOUR Center University of Alberta Edmonton Alberta Canada
| | - Arnav Kumar
- Emory University School of Medicine Atlanta GA
| | | | - Ajay J Kirtane
- New York-Presbyterian Hospital/Columbia University Medical Center New York NY
| |
Collapse
|
41
|
Bui KTA, Matteau A, Elbarouni B, Bainey KR, Fordyce CB, Bagai A, Rose B, Lutchmedial S, Leis B, Lavoie A, Cox J, Mansour S, Potter BJ. Management of Acute Coronary Syndromes Beyond the First Year: A Canadian Clinical Practice Survey. CJC Open 2020; 2:619-624. [PMID: 33305222 PMCID: PMC7710997 DOI: 10.1016/j.cjco.2020.08.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2020] [Accepted: 08/05/2020] [Indexed: 10/26/2022] Open
Abstract
Background Antithrombotic management following acute coronary syndromes (ACSs) has evolved significantly. However, given lingering uncertainty as to when an ACS may be considered stable, there is the possibility of practice divergence beyond the first year. Methods An online adaptive survey describing patients with varying cardiac and extracardiac ischemic risk was developed in order to asses self-reported physician practice intentions pertaining to the antithrombotic management of ACS patients who lack a formal indication for therapeutic anticoagulation. Provincial "champions" (Prince Edward Island not represented) were identified to ensure dissemination of the survey within their jurisdictions via 3 coordinated e-mailings; the survey was made available in French and English from November 2018 through January 2019. Results A total of 135 practitioners responded to the survey (response rate 15%). Surveys were fully completed in all cases. Nearly all respondents (97%) were cardiologists; 76% worked at an academic center, and 54% had been in practice ≥ 10 years. Most respondents (81%-90%, depending on the scenario) preferred ticagrelor-based dual antiplatelet therapy as the initial ACS treatment. However, beyond 12 months, management decisions differed significantly according to the balance of cardiac and extracardiac risk. Conclusions This study provides a first look at how the introduction of rivaroxaban 2.5 mg might be integrated into the clinical management of ACS patients beyond the first year in Canada. Whether to pursue dual antiplatelet therapy or transition early to low-dose rivaroxaban plus acetylsalicylic acid will likely be driven by patient clinical characteristics and perceived cardiac vs extra-cardiac ischemic risk.
Collapse
Affiliation(s)
- Khai-Tuan A Bui
- Cardiology Service, Department of Medicine, University of Montreal Hospital Centre (CHUM), Montreal, Quebec, Canada.,Health Innovation and Evaluation Hub, Research Center of the CHUM (CRCHUM), Montreal, Quebec, Canada
| | - Alexis Matteau
- Cardiology Service, Department of Medicine, University of Montreal Hospital Centre (CHUM), Montreal, Quebec, Canada.,Health Innovation and Evaluation Hub, Research Center of the CHUM (CRCHUM), Montreal, Quebec, Canada
| | - Basem Elbarouni
- Cardiology Division, Department of Medicine, St-Boniface Hospital, Winnipeg, Manitoba, Canada
| | - Kevin R Bainey
- Cardiology Division, Department of Medicine, Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Alberta, Canada
| | | | - Akshay Bagai
- Cardiology Division, Department of Medicine, Terrence Donnelly Heart Center, St Michael's Hospital, Toronto, Ontario, Canada
| | - Barry Rose
- Cardiology Division, Department of Medicine, Eastern Health/Memorial University, St John's, Newfoundland and Labrador, Canada
| | - Sohrab Lutchmedial
- Cardiology Division, Department of Medicine, New Brunswick Heart Centre, Saint John, New Brunswick, Canada
| | - Benjamin Leis
- Cardiology Division, Department of Medicine, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Andrea Lavoie
- Cardiology Division, Department of Medicine, University of Saskatchewan, Regina, Saskatchewan, Canada
| | - Jafna Cox
- Cardiology Division, Department of Medicine, Queen Elizabeth II Health Sciences Centre, Halifax, Nova Scotia, Canada
| | - Samer Mansour
- Cardiology Service, Department of Medicine, University of Montreal Hospital Centre (CHUM), Montreal, Quebec, Canada.,Health Innovation and Evaluation Hub, Research Center of the CHUM (CRCHUM), Montreal, Quebec, Canada
| | - Brian J Potter
- Cardiology Service, Department of Medicine, University of Montreal Hospital Centre (CHUM), Montreal, Quebec, Canada.,Health Innovation and Evaluation Hub, Research Center of the CHUM (CRCHUM), Montreal, Quebec, Canada
| |
Collapse
|
42
|
Dhoot A, Liu S, Savu A, Cheema ZM, Welsh RC, Bainey KR, Ko DT, Bhavnani SP, Goodman SG, Kaul P, Bagai A. Cardiac Stress Testing After Coronary Revascularization. Am J Cardiol 2020; 136:9-14. [PMID: 32946857 DOI: 10.1016/j.amjcard.2020.08.051] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2020] [Revised: 08/26/2020] [Accepted: 08/28/2020] [Indexed: 12/21/2022]
Abstract
Unless prompted by symptoms or change in clinical status, the appropriate use criteria consider cardiac stress testing (CST) within 2 years of percutaneous coronary intervention (PCI) and 5 years of coronary artery bypass grafting (CABG) to be rarely appropriate. Little is known regarding use and yield of CST after PCI or CABG. We studied 39,648 patients treated with coronary revascularization (29,497 PCI; 10,151 CABG) between April 2004 and March 2012 in Alberta, Canada. Frequency of CST between 60 days and 2 years after revascularization was determined from linked provincial databases. Yield was defined as subsequent rates of coronary angiography and revascularization after CST. Post PCI, 14,195 (48.1%) patients underwent CST between 60 days and 2 years, while post CABG, 4,469 (44.0%) patients underwent CST. Compared with patients not undergoing CST, patients undergoing CST were more likely to be of younger age, reside in an urban area, have higher neighborhood median household income, but less medical comorbidities. Among PCI patients undergoing CST, 5.2% underwent subsequent coronary angiography, and 2.6% underwent repeat revascularization within 60 days of CST. Rates of coronary angiography and repeat revascularization post-CST among CABG patients were 3.6% and 1.1%, respectively. Approximately one-half of patients undergo CST within 2 years of PCI or CABG in Alberta, Canada. Yield of CST is low, with only 1 out of 38 tested post-PCI patients and 1 out of 91 tested post-CABG patients undergoing further revascularization. In conclusion, additional research is required to determine patients most likely to benefit from CST after revascularization.
Collapse
|
43
|
Sheth T, Pinilla-Echeverri N, Moreno R, Wang J, Wood DA, Storey RF, Mehran R, Bainey KR, Bossard M, Bangalore S, Schwalm JD, Velianou JL, Valettas N, Sibbald M, Rodés-Cabau J, Ducas J, Cohen EA, Bagai A, Rinfret S, Newby DE, Feldman L, Laster SB, Lang IM, Mills JD, Cairns JA, Mehta SR. Nonculprit Lesion Severity and Outcome of Revascularization in Patients With STEMI and Multivessel Coronary Disease. J Am Coll Cardiol 2020; 76:1277-1286. [PMID: 32912441 DOI: 10.1016/j.jacc.2020.07.034] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Accepted: 07/10/2020] [Indexed: 11/20/2022]
Abstract
BACKGROUND In the COMPLETE (Complete vs Culprit-only Revascularization to Treat Multi-vessel Disease After Early PCI for STEMI) trial, angiography-guided percutaneous coronary intervention (PCI) of nonculprit lesions with the aim of complete revascularization reduced major cardiovascular (CV) events in patients with ST-segment elevation myocardial infarction (MI) and multivessel coronary artery disease. OBJECTIVES The purpose of this study was to determine the effect of nonculprit-lesion stenosis severity measured by quantitative coronary angiography (QCA) on the benefit of complete revascularization. METHODS Among 4,041 patients randomized in the COMPLETE trial, nonculprit lesion stenosis severity was measured using QCA in the angiographic core laboratory in 3,851 patients with 5,355 nonculprit lesions. In pre-specified analyses, the treatment effect in patients with QCA stenosis ≥60% versus <60% on the first coprimary outcome of CV death or new MI and the second co-primary outcome of CV death, new MI, or ischemia-driven revascularization was determined. RESULTS The first coprimary outcome was reduced with complete revascularization in the 2,479 patients with QCA stenosis ≥60% (2.5%/year vs. 4.2%/year; hazard ratio [HR]: 0.61; 95% confidence interval [CI]: 0.47 to 0.79), but not in the 1,372 patients with QCA stenosis <60% (3.0%/year vs. 2.9%/year; HR: 1.04; 95% CI: 0.72 to 1.50; interaction p = 0.02). The second coprimary outcome was reduced in patients with QCA stenosis ≥60% (2.9%/year vs. 6.9%/year; HR: 0.43; 95% CI: 0.34 to 0.54) to a greater extent than patients with QCA stenosis <60% (3.3%/year vs. 5.2%/year; HR: 0.65; 95% CI: 0.47 to 0.89; interaction p = 0.04). CONCLUSIONS Among patients with ST-segment elevation MI and multivessel coronary artery disease, complete revascularization reduced major CV outcomes to a greater extent in patients with stenosis severity of ≥60% compared with <60%, as determined by quantitative coronary angiography.
Collapse
Affiliation(s)
- Tej Sheth
- Population Health Research Institute, Hamilton, Ontario, Canada; McMaster University, Hamilton Health Sciences, Hamilton, Ontario, Canada. https://twitter.com/PHRIresearch
| | - Natalia Pinilla-Echeverri
- Population Health Research Institute, Hamilton, Ontario, Canada; McMaster University, Hamilton Health Sciences, Hamilton, Ontario, Canada
| | | | - Jia Wang
- Population Health Research Institute, Hamilton, Ontario, Canada; McMaster University, Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - David A Wood
- University of British Columbia, Vancouver, British Columbia, Canada
| | - Robert F Storey
- Department of Infection, Immunity, and Cardiovascular Disease, University of Sheffield, Sheffield, United Kingdom
| | - Roxana Mehran
- Zena A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Kevin R Bainey
- University of Alberta, Mazankowski Alberta Heart Institute, Edmonton, Alberta, Canada
| | - Matthias Bossard
- Cardiology Division, Heart Center, Luzerner Kantonsspital, Luzern, Switzerland
| | | | - Jon-David Schwalm
- Population Health Research Institute, Hamilton, Ontario, Canada; McMaster University, Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - James L Velianou
- McMaster University, Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - Nicholas Valettas
- McMaster University, Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - Matthew Sibbald
- McMaster University, Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - Josep Rodés-Cabau
- Quebec Heart & Lung Institute, Laval University, Quebec City, Quebec, Canada
| | - John Ducas
- University of Manitoba, Winnipeg, Manitoba, Canada
| | - Eric A Cohen
- Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Akshay Bagai
- Terrence Donnelly Heart Centre, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | | | | | - Laurent Feldman
- Hôpital Bichat, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Steven B Laster
- St. Luke's Mid-America Heart Institute, University of Missouri-Kansas City School of Medicine, Kansas City, Missouri
| | - Irene M Lang
- Vienna General Hospital, Medical University of Vienna, Vienna, Austria
| | - Joseph D Mills
- Liverpool Heart and Chest Hospital, Liverpool, United Kingdom
| | - John A Cairns
- University of British Columbia, Vancouver, British Columbia, Canada
| | - Shamir R Mehta
- Population Health Research Institute, Hamilton, Ontario, Canada; McMaster University, Hamilton Health Sciences, Hamilton, Ontario, Canada. https://twitter.com/PHRIresearch
| |
Collapse
|
44
|
Bainey KR, Engstrøm T, Smits PC, Gershlick AH, James SK, Storey RF, Wood DA, Mehran R, Cairns JA, Mehta SR. Complete vs Culprit-Lesion-Only Revascularization for ST-Segment Elevation Myocardial Infarction: A Systematic Review and Meta-analysis. JAMA Cardiol 2020; 5:881-888. [PMID: 32432651 DOI: 10.1001/jamacardio.2020.1251] [Citation(s) in RCA: 43] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance Recently, the Complete vs Culprit-Only Revascularization to Treat Multivessel Disease After Early PCI (percutaneous coronary intervention) for STEMI (ST-segment elevation myocardial infarction [MI]) (COMPLETE) trial showed that angiography-guided PCI of the nonculprit lesion with the goal of complete revascularization reduced cardiovascular (CV) death or new MI compared with PCI of the culprit lesion only in STEMI. Whether complete revascularization also reduces CV mortality is uncertain. Moreover, whether the association of complete revascularization with hard clinical outcomes is consistent when fractional flow reserve (FFR)- and angiography-guided strategies are used is unknown. Objective To determine through a systematic review and meta-analysis (1) whether complete revascularization is associated with decreased CV mortality and (2) whether heterogeneity in the association occurs when FFR- and angiography-guided PCI strategies for nonculprit lesions are performed. Data Sources A systematic search of MEDLINE, Embase, ISI Web of Science, and CENTRAL (Cochrane Central Register of Controlled Trials) from database inception to September 30, 2019, was performed. Conference proceedings were also reviewed from January 1, 2002, to September 30, 2019. Study Selection English-language randomized clinical trials comparing complete revascularization vs culprit-lesion-only PCI in patients with STEMI and multivessel disease were included. Data Extraction and Synthesis The combined odds ratio (OR) was calculated with the random-effects model using the Mantel-Haenszel method (sensitivity with fixed-effects model). Heterogeneity was measured using the I2 statistic. Publication bias was evaluated using the inverted funnel plot approach. Data were analyzed from October 2019 to January 2020. Main Outcomes and Measures Cardiovascular death and the composite of CV death or new MI. Results Ten randomized clinical trials involving 7030 unique patients were included. The weighted mean follow-up time was 29.5 months. Complete revascularization was associated with reduced CV death compared with culprit-lesion-only PCI (80 of 3191 [2.5%] vs 106 of 3406 [3.1%]; OR, 0.69 [95% CI, 0.48-0.99]; P = .05; fixed-effects model OR, 0.74 [95% CI, 0.55-0.99]; P = .04). All-cause mortality occurred in 153 of 3426 patients (4.5%) in the complete revascularization group vs 177 of 3604 (4.9%) in the culprit-lesion-only group (OR, 0.84 [95% CI, 0.67-1.05]; P = .13; I2 = 0%). Complete revascularization was associated with a reduced composite of CV death or new MI (192 of 2616 [7.3%] vs 266 of 2586 [10.3%]; OR, 0.69 [95% CI, 0.55-0.87]; P = .001; fixed-effects model OR, 0.69 [95% CI, 0.57-0.84]; P < .001), with no heterogeneity in this outcome when complete revascularization was performed using an FFR-guided strategy (OR, 0.78 [95% CI, 0.43-1.44]) or an angiography-guided strategy (OR, 0.61 [95% CI, 0.38-0.97]; P = .52 for interaction). Conclusions and Relevance In patients with STEMI and multivessel disease, complete revascularization was associated with a reduction in CV mortality compared with culprit-lesion-only PCI. There was no differential association with treatment between FFR- and angiography-guided strategies on major CV outcomes.
Collapse
Affiliation(s)
- Kevin R Bainey
- Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Alberta, Canada
| | - Thomas Engstrøm
- The Heart Center, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Pieter C Smits
- Department of Cardiology, Maasstad Ziekenhuis, Rotterdam, the Netherlands
| | - Anthony H Gershlick
- Department of Cardiovascular Sciences, University of Leicester and NIHR (National Institute of Heath Research) Leicester Cardiovascular Biomedical Research Unit, University Hospitals of Leicester NHS (National Health Service) Trust, Glenfield Hospital, Leicester, United Kingdom
| | - Stefan K James
- Department of Medical Sciences, Uppsala University, Uppsala, Sweden
| | - Robert F Storey
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, United Kingdom
| | - David A Wood
- Centre for Cardiovascular Innovation, University of British Columbia, Vancouver, British Columbia, Canada
| | - Roxana Mehran
- Zena and Michael A. Weiner Cardiovascular Institute, Mount Sinai School of Medicine, New York, New York
| | - John A Cairns
- Division of Cardiology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Shamir R Mehta
- Population Health Research Institute, Hamilton Health Sciences, McMaster University, Hamilton, Ontario, Canada
| |
Collapse
|
45
|
Pinilla-Echeverri N, Mehta SR, Wang J, Lavi S, Schampaert E, Cantor WJ, Bainey KR, Welsh RC, Kassam S, Mehran R, Storey RF, Nguyen H, Meeks B, Wood DA, Cairns JA, Sheth T. Nonculprit Lesion Plaque Morphology in Patients With ST-Segment–Elevation Myocardial Infarction. Circ Cardiovasc Interv 2020; 13:e008768. [DOI: 10.1161/circinterventions.119.008768] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Background:
Complete revascularization with routine percutaneous coronary intervention of nonculprit lesions after primary percutaneous coronary intervention improves outcomes in ST-segment–elevation myocardial infarction. Whether this benefit is associated with nonculprit lesion vulnerability is unknown.
Methods:
In a prospective substudy of the COMPLETEs trial (Complete vs Culprit-Only Revascularization to Treat Multi-Vessel Disease After Early PCI for STEMI), we performed optical coherence tomography of at least 2 coronary arteries before nonculprit lesion percutaneous coronary intervention in 93 patients with ST-segment–elevation myocardial infarction and multivessel disease; and the ST-segment–elevation myocardial infarction culprit vessel if there was unstented segment amenable to imaging. Nonculprit lesions were categorized as obstructive (≥70% stenosis by visual angiographic assessment) or nonobstructive, and as thin-cap fibroatheroma (TCFA) or non-TCFA by optical coherence tomography criteria. TCFA was defined as a lesion with mean fibrous cap thickness <65 μm overlying a lipid arc >90°.
Results:
On a patient level, at least one obstructive TCFA was observed in 44/93 (47%) of patients. On a lesion level, there were 58 TCFAs among 150 obstructive nonculprit lesions compared with 74 TCFAs among 275 nonculprit lesions (adjusted TCFA prevalence: 35.4% versus 23.2%,
P
=0.022). Compared with obstructive non-TCFAs, obstructive TCFAs had similar lesion length (23.1 versus 20.8 mm,
P
=0.16) but higher lipid quadrants (55.2 versus 19.2,
P
<0.001), greater mean lipid arc (203.8° versus 84.5°,
P
<0.001), and more macrophages (97.1% versus 54.4%,
P
<0.001) and cholesterol crystals (85.8% versus 44.3%,
P
<0.001). For nonobstructive lesions, TCFA lesions had similar lesion length (16.7 versus 14.6 mm,
P
=0.11), but more lipid quadrants (36.4 versus 13.5,
P
<0.001), and greater mean lipid arc (191.8° versus 84.2°,
P
<0.001) compared with non-TCFA.
Conclusions:
Among patients who underwent optical coherence tomography imaging in the COMPLETE trial, nearly 50% had at least one obstructive nonculprit lesion containing complex vulnerable plaque. Obstructive lesions more commonly harbored vulnerable plaque morphology than nonobstructive lesions. This may help explain the benefit of routine percutaneous coronary intervention of obstructive nonculprit lesions in patients with ST-segment–elevation myocardial infarction and multivessel disease.
Registration:
URL:
https://www.clinicaltrials.gov
. Unique identifier: NCT01740479s.
Collapse
Affiliation(s)
- Natalia Pinilla-Echeverri
- Population Health Research Institute, McMaster University and Hamilton Health Sciences, ON, Canada (N.P.-E., S.R.M., J.W., H.N., B.M., T.S.)
| | - Shamir R. Mehta
- Population Health Research Institute, McMaster University and Hamilton Health Sciences, ON, Canada (N.P.-E., S.R.M., J.W., H.N., B.M., T.S.)
| | - Jia Wang
- Population Health Research Institute, McMaster University and Hamilton Health Sciences, ON, Canada (N.P.-E., S.R.M., J.W., H.N., B.M., T.S.)
| | - Shahar Lavi
- London Health Sciences Centre, Western University, ON, Canada (S.L.)
| | - Erick Schampaert
- Hôpital du Sacré-Cœur de Montréal, Université de Montréal, QC, Canada (E.S.)
| | - Warren J. Cantor
- Southlake Regional Health Centre, University of Toronto, ON, Canada (W.J.C.)
| | - Kevin R. Bainey
- Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, AB, Canada (K.R.B., R.C.W.)
| | - Robert C. Welsh
- Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, AB, Canada (K.R.B., R.C.W.)
| | - Saleem Kassam
- Scarborough Health Network–Centenary site, ON, Canada (S.K.)
| | - Roxana Mehran
- The Zena A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY (R.M.)
| | - Robert F. Storey
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, United Kingdom (R.F.S.)
| | - Helen Nguyen
- Population Health Research Institute, McMaster University and Hamilton Health Sciences, ON, Canada (N.P.-E., S.R.M., J.W., H.N., B.M., T.S.)
| | - Brandi Meeks
- Population Health Research Institute, McMaster University and Hamilton Health Sciences, ON, Canada (N.P.-E., S.R.M., J.W., H.N., B.M., T.S.)
| | - David A. Wood
- Centre for Cardiovascular Innovation, St Paul’s and Vancouver General Hospitals, University of British Columbia, Vancouver, Canada (D.A.W., J.A.C.)
| | - John A. Cairns
- Centre for Cardiovascular Innovation, St Paul’s and Vancouver General Hospitals, University of British Columbia, Vancouver, Canada (D.A.W., J.A.C.)
| | - Tej Sheth
- Population Health Research Institute, McMaster University and Hamilton Health Sciences, ON, Canada (N.P.-E., S.R.M., J.W., H.N., B.M., T.S.)
| |
Collapse
|
46
|
Jabir A, Mathew A, Zheng Y, Westerhout C, Viswanathan S, Sebastian P, Kumar P, Bangalore S, Bainey KR, Welsh R. Procedural Volume and Outcomes After Primary Percutaneous Coronary Intervention for ST-Segment-Elevation Myocardial Infarction in Kerala, India: Report of the Cardiological Society of India-Kerala Primary Percutaneous Coronary Intervention Registry. J Am Heart Assoc 2020; 9:e014968. [PMID: 32476563 PMCID: PMC7429028 DOI: 10.1161/jaha.119.014968] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Background There are limited data to inform policy mandating primary percutaneous coronary intervention (PPCI) volume benchmarks for catheterization laboratories in low‐ and middle‐income countries. Methods and Results This prospective state‐wide registry included ST‐segment–elevation myocardial infarction patients with symptoms of <12 hours, or with ongoing ischemia at 12 to 24 hours, reperfused with PPCI. From June 2013 to March 2016, we recruited 5560 consecutive patients. We categorized hospitals on the basis of annual PPCI volumes into low, medium, and high volume (<100, 100–199, and ≥200 PPCIs per year, respectively). Kaplan‐Meier curves and Cox regression models were used to examine the association between PPCI volume and 1‐year mortality. Among 42 recruiting hospitals, there were 24 (57.2%) low‐volume, 8 (19%) medium‐volume, and 10 (23.8%) high‐volume hospitals. The median (25th–75th percentile) TIMI (Thrombolysis in Myocardial Infarction) ST‐segment–elevation myocardial infarction risk score was 3 (2–5). Cardiac arrest before admission occurred in 4.2%, 2.1%, and 2.9% of cases at low‐, medium‐, and high‐volume hospitals, respectively (P=0.02). Total ischemic time differed significantly among low‐volume (median [25th–75th percentile], 3.5 [2.4–5.5] hours), medium‐volume (median, 3.8 [25th–75th percentile, 2.58–6.05] hours), and high‐volume hospitals (median, 4.16 [25th–75th percentile 2.8–6.3] hours) (P=0.01). Vascular access was radial in 61.5%, 71.3%, and 63.2% of cases at low‐, medium‐, and high‐volume hospitals, respectively (P=0.01). The observed 1‐year mortality rate was 6.5%, 3.4%, and 8.6% at low‐, medium‐ and high‐volume hospitals, respectively (P<0.01), and the difference did not attenuate after multivariate adjustment (low versus medium: hazard ratio [95% CI], 1.80 [1.12–2.90]; high versus medium: hazard ratio [95% CI], 2.53 [1.78–3.58]) (P<0.01). Conclusions Low‐ and middle‐income countries, like India, may have a nonlinear relationship between institutional PPCI volume and outcomes, partly driven by procedural variations and inequalities in access to care.
Collapse
Affiliation(s)
| | - Anoop Mathew
- Canadian VIGOUR Centre Li Ka Shing Centre for Health Research Innovation University of Alberta Edmonton Alberta Canada.,Division of Cardiology Mazankowski Alberta Heart Institute University of Alberta Edmonton Alberta Canada
| | - Yinggan Zheng
- Canadian VIGOUR Centre Li Ka Shing Centre for Health Research Innovation University of Alberta Edmonton Alberta Canada
| | - Cynthia Westerhout
- Canadian VIGOUR Centre Li Ka Shing Centre for Health Research Innovation University of Alberta Edmonton Alberta Canada
| | - Sunitha Viswanathan
- Division of Cardiology Government Medical College Hospital Thiruvanathapuram Kerala India
| | - Placid Sebastian
- Division of Cardiology Pariyaram Medical College Hospital Kannur Kerala India
| | - Prasanna Kumar
- Jubilee Medical College Hospital and Research Centre Thrissur Kerala India
| | | | - Kevin R Bainey
- Canadian VIGOUR Centre Li Ka Shing Centre for Health Research Innovation University of Alberta Edmonton Alberta Canada.,Division of Cardiology Mazankowski Alberta Heart Institute University of Alberta Edmonton Alberta Canada
| | - Robert Welsh
- Canadian VIGOUR Centre Li Ka Shing Centre for Health Research Innovation University of Alberta Edmonton Alberta Canada.,Division of Cardiology Mazankowski Alberta Heart Institute University of Alberta Edmonton Alberta Canada
| |
Collapse
|
47
|
Wijeysundera HC, Henning KA, Qiu F, Adams C, Al Qoofi F, Asgar A, Austin P, Bainey KR, Cohen EA, Daneault B, Fremes S, Kass M, Ko DT, Lambert L, Lauck SB, MacFarlane K, Nadeem SN, Oakes G, Paddock V, Pelletier M, Peterson M, Piazza N, Potter BJ, Radhakrishnan S, Rodes-Cabau J, Toleva O, Webb JG, Welsh R, Wood D, Woodward G, Zimmermann R. Inequity in Access to Transcatheter Aortic Valve Replacement: A Pan-Canadian Evaluation of Wait-Times. Can J Cardiol 2020; 36:844-851. [DOI: 10.1016/j.cjca.2019.10.018] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2019] [Revised: 10/13/2019] [Accepted: 10/21/2019] [Indexed: 01/03/2023] Open
|
48
|
Bainey KR, Bates ER, Armstrong PW. ST-Segment-Elevation Myocardial Infarction Care and COVID-19: The Value Proposition of Fibrinolytic Therapy and the Pharmacoinvasive Strategy. Circ Cardiovasc Qual Outcomes 2020; 13:e006834. [PMID: 32339038 DOI: 10.1161/circoutcomes.120.006834] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Kevin R Bainey
- Canadian VIGOUR Center, Division of Cardiology, Department of Medicine, University of Alberta, Edmonton, Canada (K.R.B., P.W.A.)
| | - Eric R Bates
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor (E.R.B.)
| | - Paul W Armstrong
- Canadian VIGOUR Center, Division of Cardiology, Department of Medicine, University of Alberta, Edmonton, Canada (K.R.B., P.W.A.)
| |
Collapse
|
49
|
Sluchinski SL, Pituskin E, Bainey KR, Norris CM. A Review of the Evidence for Treatment of Myocardial Infarction With Nonobstructive Coronary Arteries. CJC Open 2020; 2:395-401. [PMID: 32995725 PMCID: PMC7499383 DOI: 10.1016/j.cjco.2020.03.016] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2020] [Accepted: 03/30/2020] [Indexed: 11/18/2022] Open
Abstract
Myocardial infarction (MI) with non-obstructive coronary arteries (MINOCA) is reported in 6% of patients with acute MI referred for catheterization. Because of the complex etiology and a limited amount of evidence, the treatment of MINOCA remains elusive. The etiology of MINOCA manifests from several causes including plaque disruption or erosion, epicardial coronary artery vasospasm, and coronary microvascular dysfunction. In addition, spontaneous coronary artery dissection, takotsubo, and myocarditis have been identified as contributing to the diagnosis of MINOCA. Patients with MINOCA are frequently young, non-white females with fewer traditional risk factors compared with those with an MI caused by obstructive coronary disease. Moreover, women who suffered an MI are 5 times more likely to be diagnosed with MINOCA with a trend for worse outcomes compared with men. The increased recognition/diagnosis of MINOCA has highlighted a gap in our understanding of the treatment of MINOCA. This review identified that there is a paucity of evidence on treatment strategies for patients clinically diagnosed with MINOCA, but more importantly that MINOCA should be viewed as a "syndrome" with many different pathologic causes. This suggests that a standard protocol may not be useful for patients with MINOCA. Given the ongoing debate over the complexity of MINOCA, the main focus in the management of MINOCA should be to identify the underlying mechanism for targeted therapies that may optimize outcomes.
Collapse
Affiliation(s)
- Shelby L. Sluchinski
- Faculty of Nursing, University of Alberta, Edmonton, Alberta, Canada
- Corresponding author: Shelby L. Sluchinski, Faculty of Nursing, 5-246 Edmonton Clinic Health Academy, University of Alberta, Edmonton, Alberta T6G 1C9, Canada. Tel: +1-780-619-1253.
| | - Edith Pituskin
- Faculty of Nursing, University of Alberta, Edmonton, Alberta, Canada
| | - Kevin R. Bainey
- Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Alberta, Canada
| | - Colleen M. Norris
- Faculty of Nursing, University of Alberta, Edmonton, Alberta, Canada
| |
Collapse
|
50
|
Bainey KR, Welsh RC, Connolly SJ, Marsden T, Bosch J, Fox KA, Steg PG, Vinereanu D, Connolly DL, Berkowitz SD, Foody JM, Probstfield JL, Branch KR, Lewis BS, Diaz R, Muehlhofer E, Widimsky P, Yusuf S, Eikelboom JW, Bhatt DL. Rivaroxaban Plus Aspirin Versus Aspirin Alone in Patients With Prior Percutaneous Coronary Intervention (COMPASS-PCI). Circulation 2020; 141:1141-1151. [DOI: 10.1161/circulationaha.119.044598] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background:
The COMPASS trial (Cardiovascular Outcomes for People using Anticoagulation Strategies) demonstrated that dual pathway inhibition (DPI) with rivaroxaban 2.5 mg twice daily plus aspirin 100 mg once daily versus aspirin 100 mg once daily reduced the primary major adverse cardiovascular event (MACE) outcome of cardiovascular death, myocardial infarction, or stroke, as well as, mortality, in patients with chronic coronary syndromes or peripheral arterial disease. Whether this remains true in patients with a history of percutaneous coronary intervention (PCI) is unknown.
Methods:
In a prespecified subgroup analysis from COMPASS, we examined the outcomes of patients with a chronic coronary syndrome with or without a previous PCI treated with DPI versus aspirin alone. Among patients with a previous PCI, we studied the effects of treatment according to the timing of the previous PCI.
Results:
Of the 27 395 patients in COMPASS, 16 560 patients with a chronic coronary syndrome were randomly assigned to DPI or aspirin, and, of these, 9862 (59.6%) had previous PCI (mean age 68.2±7.8, female 19.4%, diabetes mellitus 35.7%, previous myocardial infarction 74.8%, multivessel PCI 38.0%). Average time from PCI to randomization was 5.4 years (SD, 4.4) and follow-up was 1.98 (SD, 0.72) years. Regardless of previous PCI, DPI versus aspirin produced consistent reductions in MACE (PCI: 4.0% versus 5.5%; hazard ratio [HR], 0.74 [95% CI, 0.61–0.88]; no PCI: 4.4% versus 5.7%; HR, 0.76 [95% CI, 0.61–0.94],
P
-interaction=0.85) and mortality (PCI: 2.5% versus 3.5%; HR, 0.73 [95% CI, 0.58–0.92]; no PCI: 4.1% versus 5.0%; HR, 0.80 [95% CI, 0.64–1.00],
P
-interaction=0.59), but increased major bleeding (PCI: 3.3% versus 2.0%; HR, 1.72 [95% CI, 1.34–2.21]; no PCI: 2.9% versus 1.8%; HR, 1.58 [95% CI, 1.15–2.17],
P
-interaction=0.68). In those with previous PCI, DPI compared with aspirin produced consistent (robust) reductions in MACE irrespective of time since previous PCI (as early as 1 year and as far as 10 years;
P
-interaction=0.65), irrespective of having a previous myocardial infarction (
P
-interaction=0.64).
Conclusions:
DPI compared with aspirin produced consistent reductions in MACE and mortality but with increased major bleeding with or without previous PCI. Among those with previous PCI 1 year and beyond, the effects on MACE and mortality were consistent irrespective of time since last PCI.
Registration:
URL:
https://www.clinicaltrials.gov
; Unique identifier: NCT01776424.
Collapse
Affiliation(s)
- Kevin R. Bainey
- Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Canada (K.R.B., R.C.W.)
| | - Robert C. Welsh
- Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Canada (K.R.B., R.C.W.)
| | - Stuart J. Connolly
- Population Heath Research Institute, McMaster University and Hamilton Health Sciences, ON, Canada (S.J.C., T.M., J.B., S.Y., J.W.E.)
| | - Tamara Marsden
- Population Heath Research Institute, McMaster University and Hamilton Health Sciences, ON, Canada (S.J.C., T.M., J.B., S.Y., J.W.E.)
| | - Jackie Bosch
- Population Heath Research Institute, McMaster University and Hamilton Health Sciences, ON, Canada (S.J.C., T.M., J.B., S.Y., J.W.E.)
| | - Keith A.A. Fox
- Department of Medicine, University of Edinburgh, UK (K.A.A.F.)
| | | | - Dragos Vinereanu
- University of Medicine and Pharmacy Carol Davila, Bucharest, Romania (D.V.)
| | | | | | | | | | | | - Basil S. Lewis
- Lady Davis Carmel Medical Center, Haifa, Israel (B.S.L.)
| | - Rafael Diaz
- Estudios Clínicos Latino América and Instituto Cardiovascular de Rosario, Argentina (R.D.)
| | | | | | - Salim Yusuf
- Population Heath Research Institute, McMaster University and Hamilton Health Sciences, ON, Canada (S.J.C., T.M., J.B., S.Y., J.W.E.)
| | - John W. Eikelboom
- Population Heath Research Institute, McMaster University and Hamilton Health Sciences, ON, Canada (S.J.C., T.M., J.B., S.Y., J.W.E.)
| | - Deepak L. Bhatt
- Brigham and Women’s Hospital Heart and Vascular Center and Harvard Medical School, Boston, MA (D.L.B.)
| | | |
Collapse
|