A case report of ventricular fibrillation following Shockwave intravascular lithotripsy during percutaneous coronary intervention

BACKGROUND

Shockwave intravascular lithotripsy (S-IVL) is widely used during percutaneous coronary intervention (PCI) of calcified coronary arteries. Ventricular capture beats during S-IVL are common but arrhythmias are rare.

CASE PRESENTATION

A 75-year-old woman was scheduled for PCI to a short, heavily calcified chronic total occlusion of the right coronary artery. After wiring of the occlusion, S-IVL was used to predilated the calcified stenosis. During S-IVL, the patient developed ventricular fibrillation twice.

CONCLUSION

To our knowledge, this is only the second reported case of VF during S-IVL. Although very rare, it is important to be aware of this potential and serious complication.

Transient internal mammary artery graft stenosis on early angiography: navigating pitfalls in hybrid myocardial revascularization

OBJECTIVES

Left internal mammary artery (LIMA) graft stenoses detected at early coronary angiography may be reversible and consequently prompt unnecessary graft revision. We aim to investigate the frequency, natural course, and clinical significance of internal mammary artery graft stenosis upon early angiography in patients undergoing hybrid myocardial revascularization.

METHODS

In this retrospective sub-study of the Coronary Hybrid Revascularization Study, we compared graft appearance, ie, stenosis degree and flow, on early (in-hospital) and scheduled follow-up coronary angiography after 1 year. We assessed the change in graft patency using the Fitzgibbon classification (grade A: unimpaired runoff; grade B > 50% stenosis; grade O: occlusion), as well as graft association with adverse events (death, myocardial infarction, stroke, and repeat revascularization) at up to 5-year follow-up.

RESULTS

We report clinical follow-up data for all 131 patients included in the Coronary Hybrid Revascularization Study. Change in graft patency was analyzed in 86 patients with satisfactory visualization of the LIMA graft on early and follow-up coronary angiography. All LIMA grafts were patent at discharge and follow-up. Twenty-seven of 37 (73%) grade B graft stenoses at early angiography resolved to grade A during follow-up of median 12 months (range, 8-83 months) after surgery. Angiographically significant graft stenoses at early coronary angiography were not associated with adverse clinical outcome up to 5-year follow-up.

CONCLUSIONS

Our results suggest that the majority of clinically silent LIMA graft stenoses resolve during follow-up and are not associated with adverse clinical outcomes.

Dual-therapy CD34 antibody-covered sirolimus-eluting COMBO stents versus sirolimus-eluting Orsiro stents in patients treated with percutaneous coronary intervention: the three-year outcomes of the SORT OUT X randomised clinical trial

BACKGROUND

Target lesion failure (TLF) remains an issue with contemporary drug-eluting stents. The dual-therapy sirolimus-eluting and CD34 antibody-coated COMBO stent (DTS) was designed to improve early healing.

AIMS

We aimed to compare the 3-year outcomes of the DTS and the sirolimus-eluting Orsiro stent (SES) in all-comer patients treated with percutaneous coronary intervention.

METHODS

The SORT OUT X trial is a prospective multicentre randomised clinical trial with a registry-based follow-up comparing DTS and SES. The primary endpoint, TLF, is a composite of cardiac death, myocardial infarction or target lesion revascularisation (TLR).

RESULTS

A total of 3,146 patients were randomised to treatment with the DTS (1,578 patients) or the SES (1,568 patients). At 3 years, an intention-to-treat analysis showed that 155 patients (9.8%) who were assigned the DTS and 118 patients (7.5%) who were assigned the SES met the primary endpoint (incidence rate ratio for TLF=1.33, 95% confidence interval: 1.04-1.70; p=0.02). This difference was caused by a significantly higher TLF rate in the DTS group compared to the SES group within the first year, which was mainly explained by a higher incidence of TLR in the DTS group compared to the SES group. Of note, the TLF rates were almost identical from 1 year to 3 years in both stent groups.

CONCLUSIONS

At 3 years, the SES was superior to the DTS, mainly because the DTS was associated with an increased risk of TLF within the first year but not from 1 to 3 years.

CLINICALTRIALS

gov: NCT03216733.

Mortality Trends After Primary Percutaneous Coronary Intervention for ST-Segment Elevation Myocardial Infarction

BACKGROUND

Observational studies have reported that mortality rates after ST-segment elevation myocardial infarction (STEMI) have been stable since 2006 to 2010.

OBJECTIVES

The aim of this study was to evaluate the temporal trends in 1-year, 30-day, and 31- to 365-day mortality after STEMI in Western Denmark where primary percutaneous coronary intervention (PCI) has been the national reperfusion strategy since 2003.

METHODS

Using the Western Denmark Heart Registry, the study identified first-time PCI-treated patients undergoing primary PCI (pPCI) for STEMI from 2003 to 2018. Based on the year of pPCI, patients were divided into 4 time-interval groups and followed up for 1 year using the Danish national health registries.

RESULTS

A total of 19,613 patients were included. Median age was 64 years, and 74% were male. One-year mortality decreased gradually from 10.8% in 2003-2006, 10.4% in 2007-2010, 9.1% in 2011-2014, to 7.7% in 2015-2018 (2015-2018 vs 2003-2006: adjusted HR [aHR]: 0.71; 95% CI: 0.62-0.82). The largest absolute mortality decline occurred in the 0- to 30-day period with a 2.3% reduction (aHR: 0.69; 95% CI: 0.59-0.82), and to a lesser extent in the 31- to 365-day period (risk reduction: 1.0%; aHR: 0.71; 95% CI: 0.56-0.90).

CONCLUSIONS

In a high-income European country with a fully implemented pPCI strategy, 1-year mortality in pPCI-treated patients with STEMI decreased substantially between 2003 and 2018. Approximately three-quarters of the absolute mortality reduction occurred within the first 30 days after pPCI. These results indicate that optimization of early management of pPCI-treated patients with STEMI offers great opportunities for improving overall survival in contemporary clinical practice.

Real-World Experience with Cangrelor as Adjuvant to Percutaneous Coronary Intervention: A Single-Centre Observational Study

Background

Reversible P2Y12 inhibition can be obtained with cangrelor administered intravenously. More experience with cangrelor use in acute PCI with unknown bleeding risk is needed.

Objectives

To describe real-world use of cangrelor including patient and procedure characteristics and patient outcomes.

Methods

We performed a single-centre, retrospective, and observational study including all patients treated with cangrelor in relation to percutaneous coronary intervention at Aarhus University Hospital during the years 2016, 2017, and 2018. We recorded procedure indication and priority, the indications for cangrelor use, and patient outcomes within the first 48 hours after initiation of cangrelor treatment.

Results

We treated 991 patients with cangrelor in the study period. Of these, 869 (87.7%) had an acute procedure priority. Among acute procedures, patients were mainly treated for STEMI (n = 723) and the remaining were treated for cardiac arrest and acute heart failure. Use of oral P2Y12 inhibitors prior to percutaneous coronary intervention was rare. Fatal bleeding events (n = 6) were only observed among patients undergoing acute procedures. Stent thrombosis was observed in two patients receiving acute treatment for STEMI. Thus, cangrelor can be used in relation to PCI under acute circumstances with advantages in terms of clinical management. The benefits and risks, in terms of patient outcomes, should ideally be assessed in randomized trials.

Impact of acute coronary syndrome on clinical outcomes after revascularization with the dual-therapy CD34 antibody-covered sirolimus-eluting Combo stent and the sirolimus-eluting Orsiro stent

OBJECTIVES

To compare the efficacy and safety of the dual-therapy CD34 antibody-covered sirolimus-eluting Combo stent (DTS) and the sirolimus-eluting Orsiro stent (O-SES) in patients with and without acute coronary syndrome (ACS) included in the SORT OUT X study.

BACKGROUND

The incidence of target lesion failure (TLF) after treatment with modern drug-eluting stents has been reported to be significantly higher in patients with ACS when compared to patients without ACS. Whether the results from the SORT OUT X study apply to patients with and without ACS remains unknown.

METHODS

In total, 3146 patients were randomized to stent implantation with DTS (n = 1578; ACS: n = 856) or O-SES (n = 1568; ACS: n = 854). The primary end point, TLF, was a composite of cardiac death, target-lesion myocardial infarction (MI), or target lesion revascularization (TLR) within 1 year.

RESULTS

At 1 year, the rate of TLF was higher in the DTS group compared to the O-SES group, both among patients with ACS (6.7% vs. 4.1%; incidence rate ratio: 1.65 [95% confidence interval, CI: 1.08-2.52]) and without ACS (6.0% vs. 3.2%; incidence rate ratio: 1.88 [95% CI: 1.13-3.14]). The differences were mainly explained by higher rates of TLR, whereas rates of cardiac death and target lesion MI did not differ significantly between the two stent groups in patients with or without ACS CONCLUSION: Compared to the O-SES, the DTS was associated with a higher risk of TLF at 12 months in patients with and without ACS. The differences were mainly explained by higher rates of TLR.

Case report: Transcatheter aortic valve replacement in a large bicuspid anatomy using the XL-Myval 32 mm

Transcatheter aortic valve replacement (TAVR) is a recommended intervention for selected population with severe aortic stenosis (AS). Bicuspid aortic valve (BAV) anatomy has been categorized as an unfavorable anatomy for TAVR due to multiple considerations as exclusion from randomized trials in addition to the challenging and unpredictable anatomy. The anatomical constraints of BAV include the large anatomy of the annulus, sinus of Valsalva, and aorta (aortopathy), in addition to significant calcifications of the device landing zone. Most commercial transcatheter heart valves (THV) have upper dimension limits of the annulus and area in which the device can be implanted safely without significant oversizing. Myval-XL THVs (Meril Life Sciences Pvt. Ltd., India) are balloon-expandable valves (BEV) that have been developed with two new sizes, 30.5 and 32 mm, aiming to treat patients with large annulus dimensions and that exceed the upper limit of an ordinary device's sizing matrix. This case series report describes TAVR using the XL-Myval 32 mm THV in three European patients with symptomatic severe bicuspid aortic stenosis with significant calcifications and large annular dimensions exceeding the limits of the other THVs.

Antithrombotic treatment beyond one year after percutaneous coronary intervention in patients with atrial fibrillation

Aims

Beyond 1 year after percutaneous coronary intervention (PCI), guidelines recommend anticoagulant monotherapy in patients with atrial fibrillation (AF) rather than dual therapy with an anticoagulant and an antiplatelet drug. The risks and benefits of this strategy, however, remain uncertain. We examined hospitalization for bleeding and ischemic risk beyond 1 year after PCI in patients with AF treated with monotherapy versus dual therapy. Furthermore, among patients treated with monotherapy, we compared direct oral anticoagulant (DOAC) therapy and vitamin K antagonist (VKA) therapy.

Methods and results

We included all patients with AF undergoing first-time PCI between 2003 and 2017 from the Western Denmark Heart Registry and followed them for up to 4 years. Follow-up started 15 months after PCI to enable assessment of medical treatment after 12 months. Using a Cox regression model, we computed weighted hazard ratios (HRw) of hospitalization for bleeding and major adverse cardiac events (MACE). Analyses comparing monotherapy versus dual therapy included 3331 patients, and analyses comparing DOAC versus VKA monotherapy included 1275 patients. Risks of hospitalization for bleeding (HRw 0.90, 95% confidence interval [CI] 0.75–1.09) and MACE (HRw 1.04, 95% CI 0.90–1.19) were similar with monotherapy and dual therapy. Similarly, risks of hospitalization for bleeding (HRw 1.27, 95% CI 0.84–1.92) and MACE (HRw 1.15, 95% CI 0.87–1.50) were equal with DOAC and VKA monotherapy.

Conclusion

Our results support long-term OAC monotherapy beyond 1 year after PCI in patients with atrial fibrillation and suggest that DOAC monotherapy is as safe and effective as VKA monotherapy.

Trends in mortality and ischemic outcomes in patients with ST-segment elevation myocardial infarction following implementation of a primary percutaneous coronary intervention strategy, 2003–2017

Introduction

In Denmark, primary percutaneous coronary intervention (pPCI) has served as the national reperfusion strategy in ST-segment elevation myocardial infarction (STEMI) since 2003. Since then, extensive changes in management and treatment of patients with STEMI have been introduced. We investigated the temporal trends in one-year mortality and ischemic outcomes after STEMI.

Methods

We included all first-time STEMI patients treated with pPCI in Western Denmark from 2003 to 2017. Patients were categorized into four time periods based on year of pPCI treatment (2003–2006, 2007–2010, 2011–2014, 2015–2017) and followed for one year. Outcomes included all-cause death, recurrent myocardial infarction (MI: follow-up started after 30 days post-pPCI since the validity of recurrent MI is low in the first 30 days), and ischemic stroke. We also identified a sex and age matched comparison cohort without prior cardiovascular disease from the Western Denmark general population. Groups were compared using sex- and age-adjusted hazard ratios (aHRs) by Cox regression with the first period as reference.

Results

A total of 18,538 STEMI patients and 92,690 individuals from the general population were included. One-year mortality in STEMI patients decreased from 10.8% in 2003–2006 to 7.8% in 2015–2017 (aHR 0.70, 95% CI 0.60–0.80), while it was steady in the general population cohort (figure). The one-year risk of recurrent MI and ischemic stroke also decreased from 2003–2006 to 2015–2017 (MI: 3.5% vs. 2.4%, aHR: 0.66, 95% CI 0.51–0.86; ischemic stroke: 2.5% vs. 1.9%, aHR 0.58, 95% CI 0.42–0.80). These improvements coincided with increased up-take of evidence-based treatments, especially drug-eluting stents (39% vs. 90%), high-intensity statins (3% vs. 87%), and newer antiplatelet agents.

Conclusions

From 2003 to 2017, the one-year risk of death, recurrent MI, and ischemic stroke decreased substantially among patients with STEMI. These improvements occurred simultaneously with the gradual implementation of evidence-based guideline-directed treatments.

Funding Acknowledgement

Type of funding sources: Foundation. Main funding source(s): Aase and Ejnar Danielsen foundation

Microvascular disease increases the risk of lower limb amputation - A Western Danish cohort study

BACKGROUND

Peripheral artery disease is the leading cause of nontraumatic lower limb amputation. Microvascular disease (MVD) increases the risk of lower limb amputation in patients with peripheral artery disease (PAD). We estimated the risk of lower limb amputation associated with MVD and PAD in a Danish cohort.

METHODS

We included every resident without previous lower limb amputation in Western Denmark aged 50-75 years on 1 January 2012 and followed them for 7 years. Participants were stratified by MVD and PAD. We estimated adjusted hazard ratios of lower limb amputation using individuals with no MVD and no PAD as reference. We also provide a sex-specific analysis and estimated the population attributable fraction of the male sex.

RESULTS

We included 933,597 individuals, of whom 16,741 had MVD only, 18,217 had PAD only and 1,827 had MVD and PAD. Both MVD only (adjusted hazard ratio 3.36, 95% CI 2.98-3.73) and PAD only (adjusted hazard ratio 7.32, 95% CI 6.62-8.08) increased the risk of lower limb amputation separately. Individuals with MVD and PAD had the highest risk of amputation (adjusted hazard ratio 12.27, 95% CI 10.43-14.80). Men had an increased absolute risk of amputation. The population attributable fraction associated with the male sex was 31%.

CONCLUSIONS

Microvascular disease and PAD are independently associated with a threefold and sevenfold increase of amputation risk, respectively. Combined, they had an additive effect constituting a 12-fold amputation risk. The amputation risk was higher in men than women, and 3 in 10 amputations were attributed to the male sex.

Impact of diabetes on clinical outcomes after revascularization with the dual therapy CD34 antibody-covered sirolimus-eluting Combo stent and the sirolimus-eluting Orsiro stent

OBJECTIVES

To compare the efficacy and safety of the dual therapy CD34 antibody-covered sirolimus-eluting Combo stent (DTS) and the sirolimus-eluting Orsiro stent (SES) in patients with and without diabetes mellitus (DM) included in the Scandinavian Organization for Randomized Trials with Clinical Outcome (SORT OUT) X study.

BACKGROUND

The incidence of target lesion failure (TLF) after treatment with modern drug-eluting stents has been reported to be significantly higher in patients with DM when compared to patients without DM. Thus, whether the results from the SORT OUT X study apply to patients with and without DM remains unknown.

METHODS

In total 3146 patients were randomized to stent implantation with DTS (n = 1578; DM: n = 279) or SES (n = 1568; DM: n = 271). The primary end point, TLF, was a composite of cardiac death, target-lesion myocardial infarction (MI), or target lesion revascularization (TLR) within 1 year.

RESULTS

At 1 year, the rate of TLF was increased in the DTS group compared to the SES group, both among patients with DM (9.3% vs. 4.8%; risk difference: 4.5%; incidence rate ratio: 1.99, 95% confidence interval [CI]: 1.02-3.90) and without DM (5.7% vs. 3.5%; incidence rate ratio: 1.67, 95% CI: 1.15-2.42). The differences were mainly explained by higher rates of TLR.

CONCLUSION

Compared to the SES, the DTS was associated with an increased risk of TLF at 12 months in patients with and without DM. The differences were mainly explained by higher rates of TLR, whereas rates of cardiac death and target lesion MI did not differ significantly between the two stent groups in patients with or without DM.

CHA2 DS2 -VASc impact on risk following percutaneous coronary intervention in atrial fibrillation

AIMS

In 2010, the European Society of Cardiology Guidelines on atrial fibrillation (AF) introduced the CHA₂ DS₂ -VASc score to guide initiation of oral anticoagulation. In patients with AF undergoing percutaneous coronary intervention (PCI), triple therapy with oral anticoagulation and dual antiplatelet therapy was recommended to reduce ischaemic risk. We examined how the CHA₂ DS₂ -VASc score impacted oral anticoagulation use and risks of ischaemic and hospitalized bleeding events in patients with AF undergoing PCI.

METHODS

We included 6,014 patients with AF undergoing first-time PCI in Western Denmark between 2003 and 2017. We divided patients into four groups based on year of PCI and estimated 1-year risks of major adverse cardiac events (MACE) and hospitalization for bleeding.

RESULTS

The proportion of oral anticoagulation users was 48% in 2003-2006 and 49% in 2006-2010. Following the CHA₂ DS₂ -VASc score implementation, the proportion increased to 59% in 2011-2014 and 77% in 2015-2017. Using 2003-2006 as reference, risks of MACE were similar in 2007-2010 (adjusted relative risk [RR_adj ] 0.99, 95% confidence interval [CI] 0.83-1.18) and 2011-2014 (RR_adj 0.92, 95% CI 0.78-1.09), but declined by 23% in 2015-2017 (RR_adj 0.77, 95% CI 0.65-0.92). Hospitalizations for bleeding did not increase despite wider use of triple therapy.

CONCLUSION

Implementation of the CHA₂ DS₂ -VASc score in the 2010 European guidelines on AF was associated with an increased utilization of oral anticoagulation and triple therapy among AF patients undergoing PCI. These changes were associated with a gradual decline in the risk of MACE, while the risk of hospitalized bleeding remained unchanged.

Effectiveness and Safety of Ticagrelor Implementation in Patients with Acute Coronary Syndrome undergoing Percutaneous Coronary Intervention: A Cohort Study in Western Denmark

Background

Methods

Findings

Interpretation

Comparison of MynxGrip vascular closure device and manual compression for closure after femoral access angiography: a randomized controlled trial: the closure devices used in every day practice study, CLOSE-UP III trial

Background

Complications related to femoral artery access for coronary angiography (CAG) is a safety concern. Vascular closure devices (VCDs) have been developed to reduce the rate of complications after femoral artery access. We compared the safety and efficacy of the MynxGrip VCD versus manual compression (MC) after femoral access CAG in a randomized controlled trial.

Methods

The study was a randomized, single center, non-blinded, two-arm non-inferiority trial. The study was stopped prematurely because of low inclusion rate.

Results

We randomized 869 patients to closure with the MynxGrip VCD or MC and 865 entered analyses. The incidence of the primary endpoint of major adverse vascular events (MAVE) after 30 days was 1.2% in the MynxGrip group and 0% in the MC group (p = 0.06). The median time to hemostasis was 4 [3:5] minutes and 10 [7:11] minutes in the MynxGrip group and MC group, respectively (p < 0.0001). The corresponding median times to mobilization was 73 [65:87] minutes and 76 [70:88] minutes (p = 0.01).

Conclusions

MAVE was rare after closure of femoral arterial access by both the MynxGrip VCD and MC. We found a numerical difference in favour of MC but this did not reach statistical significance. Time to hemostasis was shorter in the MynxGrip group when compared to the MC group.

Trial registration

The study was approved by the local medical ethics committee and registered at clinicaltrials.org (ClinicalTrials identifier: NCT02237430 11/09/2014).

Risk of Myocardial Infarction and Death After Noncardiac Surgery Performed Within the First Year After Coronary Drug-Eluting Stent Implantation for Acute Coronary Syndrome or Stable Angina Pectoris

This study aimed to examine the 30-day risk of myocardial infarction (MI) and death in patients who underwent noncardiac surgery within 1 year after coronary drug-eluting stent implantation for acute coronary syndrome (ACS) or stable angina pectoris (SAP) and to compare it with the risk in surgical patients without known coronary artery disease. Patients with drug-eluting stent implantation for ACS (n = 2,291) or SAP (n = 1,804) who underwent noncardiac surgery were compared with a cohort from the general population without known coronary artery disease matched on the surgical procedure, hospital contact type, gender, and age. In patients with ACS, the 30-day MI risk was markedly increased when surgery was performed within 1 month after stenting (10% vs 0.8%; adjusted odds ratio [OR_adj] 20.1, 95% confidence interval [CI] 8.85 to 45.6), whereas mortality was comparable (10% vs 8%, OR_adj 1.17, 95% CI 0.76 to 1.79). When surgery was performed between 1 and 12 months after stenting, the 30-day absolute risk for MI was low but higher than in the comparison cohort (0.6% vs 0.2%, OR_adj 2.18, 95% CI 0.89 to 5.38), whereas the mortality risks were similar (2.0% vs 1.8%, OR_adj 1.03, 95% CI 0.69 to 1.55). In patients with SAP, the 30-day MI risk was low but higher than in the comparison cohort (0.4% vs 0.2%, OR_adj 1.90, 95% CI 0.70 to 5.14), whereas the mortality risks were similar (2.2% vs 2.1%, OR_adj 0.91, 95% CI 0.61 to 1.37). In conclusion, patients with ACS and SAP who underwent surgery between 1 and 12 months after stent implantation had a risk for MI and death that was similar to the risk observed in surgical patients without coronary artery disease.

Statin but not Aspirin Treatment is Associated with Reduced Cardiovascular Risk in Patients with Diabetes without Obstructive Coronary Artery Disease

AIMS

Patients with diabetes and no obstructive coronary artery disease (CAD) as assessed by coronary angiography (CAG) are frequently treated with aspirin and statins. We examined the effectiveness of aspirin and statin treatment on cardiovascular and bleeding incidence in patients with diabetes and absent obstructive CAD.

METHODS AND RESULTS

The study included patients with diabetes and absent obstructive CAD as assessed by CAG from 2003 to 2016 in Western Denmark. We stratified patients by aspirin and statin treatment within 6 months after CAG in two separate analyses. Outcomes were MACE (major adverse cardiovascular events, a composite of myocardial infarction, ischaemic stroke, and death) and bleeding (aspirin only). To account for confounding, we used propensity score-based weights to estimate the inverse probability of treatment-weighted hazard ratios (HRIPTW). We included 4,124 patients with diabetes but without CAD as assessed by CAG, among whom 2,474 (60%) received aspirin and 2,916 (71%) received statin treatment within 6 months following CAG. Median follow-up was 4.9 years. Aspirin did not reduce 10-year MACE (21.3% vs 21.8%, HRIPTW 1.01, 95% confidence interval (CI) 0.82-1.25), all-cause death (HRIPTW 0.96, 95% CI 0.74-1.23), or bleeding (HRIPTW 0.95, 95% CI 0.73-1.23), compared to those not receiving aspirin treatment. Statin treatment reduced MACE (25% vs. 37%, HRIPTW 0.58, 95% CI 0.48-0.70) compared to those not receiving statin treatment.

CONCLUSION

Among patients with diabetes and no obstructive CAD, aspirin neither reduced MACE nor increased bleeding. In contrast, statin treatment was associated with a major reduction in risk of MACE.

Randomized Clinical Comparison of the Dual-Therapy CD34 Antibody-Covered Sirolimus-Eluting Combo Stent With the Sirolimus-Eluting Orsiro Stent in Patients Treated With Percutaneous Coronary Intervention: The SORT OUT X Trial

BACKGROUND

Target lesion failure remains an issue with contemporary drug-eluting stents. Thus, the dual-therapy sirolimus-eluting and CD34+ antibody-coated Combo stent (DTS) was designed to further improve early healing. This study aimed to investigate whether the DTS is noninferior to the sirolimus-eluting Orsiro stent (SES) in an all-comers patient population.

METHODS

The SORT OUT X (Combo Stent Versus Orsiro Stent) trial, was a large-scale, randomized, multicenter, single-blind, 2-arm, noninferiority trial with registry-based follow-up. The primary end point target lesion failure was a composite of cardiac death, myocardial infarction, or target lesion revascularization within 12 months, analyzed using intention-to-treat. The trial was powered for assessing target lesion failure noninferiority of the DTS compared with the SES with a predetermined noninferiority margin of 0.021.

RESULTS

A total of 3146 patients were randomized to treatment with the DTS (1578 patients; 2008 lesions) or SES (1568 patients; 1982 lesions). At 12 months, intention-to-treat analysis showed that 100 patients (6.3%) assigned the DTS and 58 patients (3.7%) assigned the SES met the primary end point (absolute risk difference, 2.6% [upper limit of 1-sided 95% CI, 4.1%]; P (noninferiority)=0.76). The SES was superior to the DTS (incidence rate ratios for target lesion failure, 1.74 [95% CI, 1.26-2.41]; P=0.00086). The difference was explained mainly by a higher incidence of target lesion revascularization in the DTS group compared with the SES group (53 [3.4%] vs. 24 [1.5%]; incidence rate ratio, 2.22 [95% CI, 1.37-3.61]; P=0.0012).

CONCLUSIONS

The DTS did not confirm noninferiority to the SES for target lesion failure at 12 months in an all-comer population. The SES was superior to the DTS mainly because the DTS was associated with an increased risk of target lesion revascularization. However, rates of death, cardiac death, and myocardial infarction at 12 months did not differ significantly between the 2 stent groups. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT03216733.

Ten-year cardiovascular risk in diabetes patients without obstructive coronary artery disease: a retrospective Western Denmark cohort study

BACKGROUND

Diabetes patients without obstructive coronary artery disease as assessed by coronary angiography have a low risk of myocardial infarction, but their myocardial infarction risk may still be higher than the general population. We examined the 10-year risks of myocardial infarction, ischemic stroke, and death in diabetes patients without obstructive coronary artery disease according to coronary angiography, compared to risks in a matched general population cohort.

METHODS

We included all diabetes patients without obstructive coronary artery disease examined by coronary angiography from 2003 to 2016 in Western Denmark. Patients were matched by age and sex with a cohort from the Western Denmark general population without a previous myocardial infarction or coronary revascularization. Outcomes were myocardial infarction, ischemic stroke, and death. Ten-year cumulative incidences were computed. Adjusted hazard ratios (HR) then were computed using stratified Cox regression with the general population as reference.

RESULTS

We identified 5734 diabetes patients without obstructive coronary artery disease and 28,670 matched individuals from the general population. Median follow-up was 7 years. Diabetes patients without obstructive coronary artery disease had an almost similar 10-year risk of myocardial infarction (3.2% vs 2.9%, adjusted HR 0.93, 95% CI 0.72-1.20) compared to the general population, but had an increased risk of ischemic stroke (5.2% vs 2.2%, adjusted HR 1.87, 95% CI 1.47-2.38) and death (29.6% vs 17.8%, adjusted HR 1.24, 95% CI 1.13-1.36).

CONCLUSIONS

Patients with diabetes and no obstructive coronary artery disease have a 10-year risk of myocardial infarction that is similar to that found in the general population. However, they still remain at increased risk of ischemic stroke and death.

Instantaneous wave-free ratio guided multivessel revascularisation during percutaneous coronary intervention for acute myocardial infarction: study protocol of the randomised controlled iMODERN trial

INTRODUCTION

Recent randomised clinical trials showed benefit of non-culprit lesion revascularisation in ST-elevation myocardial infarction (STEMI) patients. However, it remains unclear whether revascularisation should be performed at the index procedure or at a later stage.

METHODS AND ANALYSIS

The instantaneous wave-free ratio (iFR) Guided Multivessel Revascularisation During Percutaneous Coronary Intervention for Acute Myocardial Infarction trial is a multicentre, randomised controlled prospective open-label trial with blinded evaluation of endpoints. After successful primary percutaneous coronary intervention (PCI), eligible STEMI patients with residual non-culprit lesions are randomised, to instantaneous wave-free ratio guided treatment of non-culprit lesions during the index procedure versus deferred cardiac MR-guided management within 4 days to 6 weeks. The primary endpoint of the study is the combined occurrence of all-cause death, recurrent myocardial infarction and hospitalisation for heart failure at 12 months follow-up. Clinical follow-up includes questionnaires at 3 months and outpatient visits at 6 months and 12 months after primary PCI. Furthermore, a cost-effectiveness analysis will be performed.

ETHICS AND DISSEMINATION

Permission to conduct this trial has been granted by the Medical Ethical Committee of the Amsterdam University Medical Centres (loc. VUmc, ID NL60107.029.16). The primary results of this trial will be shared in a main article and subgroup analyses or spin-off studies will be shared in secondary papers.

TRIAL REGISTRATION NUMBER

NCT03298659.

Peripheral artery disease, lower limb revascularization, and amputation in diabetes patients with and without coronary artery disease: a cohort study from the Western Denmark Heart Registry

INTRODUCTION

Patients with diabetes have increased risk of lower limb revascularization and amputation due to higher risk of peripheral artery disease (PAD) and peripheral neuropathy. The additive effect of coronary artery disease (CAD) is less clear. We examined the risk of PAD, lower limb revascularization, and amputation in diabetes and non-diabetes patients with and without CAD in patients examined by coronary angiography (CAG).

RESEARCH DESIGN AND METHODS

We included all patients undergoing CAG between 2003 and 2016 in Western Denmark. Patients with previous CAD, PAD, lower limb revascularization, or amputation were excluded. Patients were stratified by diabetes and CAD status and followed for a maximum of 10 years. Outcomes were PAD, lower limb revascularization, and amputation. We estimated 10-year cumulative incidences and adjusted HRs (aHRs) using patients neither diabetes nor CAD as reference.

RESULTS

A total of 118 787 patients were included, of whom 41 878 (35%) had neither diabetes nor CAD, 5735 (5%) had diabetes alone, 59 427 (50%) had CAD alone, and 11 747 (10%) had both diabetes and CAD. Median follow-up was 6.9 years. Diabetes patients without CAD had higher risk of PAD (3.5%, aHR 1.73, 95% CI 1.51 to 1.97), lower limb revascularization (1.6%, aHR 1.55, 95% CI 1.16 to 2.05), and lower limb amputation (2.4%, aHR 5.51, 95% CI 4.09 to 7.43) compared with patients with neither diabetes nor CAD. CAD was associated with 2.5-fold and 1.8-fold higher risk of PAD and amputation, respectively, among patients without diabetes, and associated with 3.9-fold and 9.5-fold higher risk of PAD and lower limb amputation among patients with diabetes.

CONCLUSIONS

Despite absence of obstructive CAD, patients with diabetes remained at higher risk of PAD, lower limb revascularization, and lower limb amputation. Diabetes was more strongly associated with amputation than CAD, but CAD exacerbated the risks of PAD, revascularization, and amputation in patients with diabetes.

Evaluation and Management of Nonculprit Lesions in STEMI

Nonculprit lesions are frequently observed in patients with ST-segment elevation myocardial infarction. Results from recent randomized clinical trials suggest that complete revascularization after ST-segment elevation myocardial infarction improves outcomes. In this state-of-the-art paper, the authors review these trials and consider how best to determine which nonculprit lesions require revascularization and when this should be performed.

Risk stratification by assessment of coronary artery disease using coronary computed tomography angiography in diabetes and non-diabetes patients: a study from the Western Denmark Cardiac Computed Tomography Registry

AIMS

We examined whether severity of coronary artery disease (CAD) measured by coronary computed tomography angiography can be used to predict rates of myocardial infarction (MI) and death in patients with and without diabetes.

METHODS AND RESULTS

A cohort study of consecutive patients (n = 48 731) registered in the Western Denmark Cardiac Computed Tomography Registry from 2008 to 2016. Patients were stratified by diabetes status and CAD severity (no, non-obstructive, or obstructive). Endpoints were MI and death. Event rates per 1000 person-years, unadjusted and adjusted incidence rate ratios were computed. Median follow-up was 3.6 years. Among non-diabetes patients, MI event rates per 1000 person-years were 1.4 for no CAD, 4.1 for non-obstructive CAD, and 9.1 for obstructive CAD. Among diabetes patients, the corresponding rates were 2.1 for no CAD, 4.8 for non-obstructive CAD, and 12.6 for obstructive CAD. Non-diabetes and diabetes patients without CAD had similar low rates of MI [adjusted incidence rate ratio 1.40, 95% confidence interval (CI): 0.71-2.78]. Among diabetes patients, the adjusted risk of MI increased with severity of CAD (no CAD: reference; non-obstructive CAD: adjusted incidence rate ratio 1.71, 95% CI: 0.79-3.68; obstructive CAD: adjusted incidence rate ratio 4.42, 95% CI: 2.14-9.17). Diabetes patients had higher death rates than non-diabetes patients, irrespective of CAD severity.

CONCLUSION

In patients without CAD, diabetes patients have a low risk of MI similar to non-diabetes patients. Further, MI rates increase with CAD severity in both diabetes and non-diabetes patients; with diabetes patients with obstructive CAD having the highest risk of MI.

High-risk pulmonary embolism with out-of-hospital cardiac arrest: Acute multidisciplinary approach leading to surgical embolectomy with good clinical outcome

Percutaneous pulmonary angiography may be used for early diagnosis of pulmonary embolism in the hemodynamic unstable patient. Pulmonary embolectomy is an effective treatment option in patients with acute high-risk pulmonary embolism.

Diabetes, coronary artery disease, and risk of dementia – a cohort study from Western Denmark

Background

Diabetes patients have a higher risk of both ischemic stroke and dementia compared to non-diabetes patients. Coronary artery disease (CAD) is associated with an increased risk of ischemic stroke. We hypothesized that diabetes and CAD are independent, and additive, risk factors for ischemic stroke and dementia.

Purpose

We examined the risk of dementia and ischemic stroke in diabetes and non-diabetes patients with and without CAD by coronary angiography.

Methods

We conducted a cohort study of all patients ≥65 years, who underwent coronary angiography between 2003–2016 in Western Denmark. Patients diagnosed with dementia or early cognitive decline at the time of CAG were excluded. Patients were stratified by diabetes and CAD. Outcomes were dementia and ischemic stroke. We estimated the cumulative incidence of a combined endpoint of dementia and ischemic stroke accounting for the competing risk of death. Follow-up was capped at the 75th percentile of overall follow-up (9.2 years). We estimated adjusted hazard ratios (aHRs) using patients without diabetes and CAD as reference. We also examined the association between extent of CAD and dementia in subgroup analysis of diabetes patients.

Results

A total of 62,372 patients were included, of whom 10,417 (16.7%) had diabetes and 43,023 (69.0%) had obstructive CAD. Median follow-up was 5.8 years. Patients with both diabetes and CAD had the highest risk of dementia (aHR 1.47, 95% CI 1.27–1.71), including Alzheimer's dementia (aHR 1.26, 95% CI 1.01–1.56) and vascular dementia (aHR 2.60, 95% CI 1.78–3.80), as well as ischemic stroke (aHR 2.02, 95% CI 1.77–2.32). Patients with either diabetes or CAD were at intermediate risk of dementia and ischemic stroke (Figure). We did not find a significant trend between the extent of CAD and risk of dementia in diabetes patients (p for trend=0.0687).

Conclusions

Both diabetes and CAD were independent risk factors of dementia and ischemic stroke in patients ≥65 years after angiography. Patients with combined diabetes and CAD had a particularly high risk of cognitive impairment and ischemic stroke.

Figure 1

Funding Acknowledgement

Type of funding source: Public hospital(s). Main funding source(s): Department of Cardiology, Aarhus University Hospital

Diabetes is not a risk factor for myocardial infarction in patients without coronary artery disease

Background

Diabetes is considered a risk factor for myocardial infarction (MI). However, we have previously found that diabetes was not a short-term risk factor for MI in the absence of obstructive coronary artery disease (CAD).

Purpose

As long-term data are not available, we aimed to assess adverse cardiac events in patients with and without diabetes stratified by CAD up to 11 years after coronary angiography.

Methods

We conducted a cohort study of patients undergoing coronary angiography from 2003 to 2012 and followed them by cross-linking Danish health registries. Patients were stratified according to the presence/absence of CAD and diabetes. Outcomes included MI, cardiac death, all-cause death, and coronary revascularization.

Results

A total of 86,202 patients were included (diabetes: n=12,652). Median follow-up was 8.8 years. Using patients with neither CAD nor diabetes as reference (cumulative MI incidence 2.6%), the risk of MI was similar for patients with diabetes alone (3.2%; hazard ratio 1.202, 95% CI: 0.996–1.451), was increased for patients with CAD alone (9.3%; hazard ratio 2.75, 95% CI: 2.52–3.01), and was highest for patients with both CAD and diabetes (12.3%; hazard ratio 3.79, 95% CI: 3.43–4.20), see Figure. Similar associations were observed for cardiac death and coronary revascularization.

Conclusions

Diabetes patients without CAD by coronary angiography have a similar risk of MI compared to patients with neither CAD nor diabetes. In the presence of CAD, however, diabetes increases the risk of MI.

Figure 1

Funding Acknowledgement

Type of funding source: Public hospital(s). Main funding source(s): The Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark.

Microvascular disease, peripheral artery disease, and the risk of lower limb amputation

Background

Peripheral artery disease (PAD) is the leading cause of non-traumatic lower limb amputation. Microvascular disease (peripheral neuropathy, nephropathy, or retinopathy) increases the risk of lower limb amputation in patients with established PAD.

Purpose

We estimated risk of lower limb amputation associated with microvascular disease and PAD in a Danish cohort.

Methods

We conducted a population-based cohort study of every person living in Western Denmark aged 50–75 years on January 1, 2012 and followed them for 7 years. People with previous lower limb amputation were excluded. People were stratified by the presence of microvascular disease (peripheral neuropathy, nephropathy, or retinopathy) and PAD (peripheral atherosclerosis including intermittent claudication, or previous lower limb revascularization). We estimated the 7-year cumulative incidence and hazard ratio (HR) of lower limb amputation using individuals with neither microvascular disease nor PAD as reference. We also provide a sex-specific analyses and estimated the population attributable fraction of amputation associated with male sex.

Results

We included 933,597 individuals, of whom 16,007 had microvascular disease, 18,400 had PAD, and 1,789 had both microvascular disease and PAD. Patients with either microvascular disease (3.7%) or PAD (3.9%) had similar unadjusted 7-year risks of lower limb amputation (Figure). Microvascular disease (adjusted HR 3.21, 95% CI 2.86–3.59) and PAD (adjusted HR 7.37, 95% CI 6.68–8.14) increased the risk of lower limb amputation separately in adjusted analysis. Individuals with both microvascular disease and PAD had the highest risk of amputation (adjusted HR 11.82, 95% CI 10.11–13.80). While the relative impact of microvascular disease and PAD were similar in men and women, men had increased risk of amputation compared to women, in absolute terms. The population attributable fraction of amputations associated with male sex was 31%.

Conclusion

Microvascular disease and PAD are independently associated with a 3-fold and 7-fold increase of amputation rate, respectively. Combined, microvascular disease and PAD had an additive effect constituting a 12-fold amputation risk. Amputation risk was higher in men than in women, with 3 in 10 lower limb amputations in Western Denmark attributable to male sex.

Figure 1

Funding Acknowledgement

Type of funding source: Public hospital(s). Main funding source(s): Department of Cardiology, Aarhus University Hospital

Cardiovascular risk of smoking in patients without obstructive coronary artery disease

Background

Smoking increases risk of cardiovascular disease by increasing atherosclerosis and thrombogenesis.

Purpose

We examined the impact of smoking on cardiovascular risk in patients without obstructive coronary artery disease (CAD) after coronary angiography.

Methods

We conducted a cohort study in patients without obstructive CAD examined by coronary angiography from 2003–2016 in Western Denmark and no previous history of MI or coronary revascularization. Smokers were compared with non-smokers (former/never smokers) and with an age- and sex matched comparison group sampled from the Western Denmark general population without a history of CAD. The main outcome was myocardial infarction (MI). Other outcomes were ischemic stroke and death. Maximum follow-up was 10 years. Adjusted hazards ratios (aHRs) were estimated using Cox regression.

Results

We identified 46,462 patients without obstructive CAD, of whom 10,879 (23%) were active smokers and 35,583 (77%) were non-smokers at the time of angiography. Patients were matched with 234,648 individuals from the general population with no previous MI or coronary revascularization. Median follow-up was 7.0 years. Smokers had higher risks of MI (aHR 1.65, 95% CI: 1.41–1.93), ischemic stroke (aHR 1.49, 95% CI: 1.28–1.74), and death (aHR 1.77, 95% CI: 1.67–1.87) compared to non-smokers undergoing CAG. As shown in the Figure, the MI risk increased immediately after start follow-up and the curves continued to diverge. Compared to the general population, smokers without obstructive CAD had a similar risk of MI (aHR 0.96, 95% CI: 0.83–1.10), but an increased risk of ischemic stroke (aHR 1.36, 95% CI: 1.19–1.56) and death (aHR 1.49, 95% CI: 1.41–1.56), while non-smokers had reduced risks of MI (aHR 0.57, 95% CI: 0.51–0.63), ischemic stroke (aHR 0.85, 95% CI: 0.78–0.93), and death (aHR 0.78, 95% CI: 0.75–0.81).

Conclusions

In patients without obstructive CAD by coronary angiography, active smoking was associated with a 65% increased 10-year risk of MI compared to non-smokers, suggesting a prothrombotic effect of smoking. Compared to a general population, with unknown CAD and smoking status, smokers examined by CAG had a similar or higher risk of cardiovascular events despite the absence of CAD, while non-smokers had a lower risk.

Figure 1

Funding Acknowledgement

Type of funding source: Public hospital(s). Main funding source(s): Department of Cardiology, Aarhus University Hospital

Ten-year cardiovascular risk in diabetes patients without of coronary artery disease – a Danish cohort study

Background

Patients with diabetes without obstructive coronary artery disease (CAD) by coronary angiography (CAG) have a risk of myocardial infarction (MI) similar to that of non-diabetes patients without CAD. Their cardiovascular risk compared to the general population is unknown.

Purpose

We examined the 10-year risks of myocardial infarction (MI), ischemic stroke, and death in diabetes patients without CAD after CAG compared to the general population.

Methods

We included all diabetes patients without obstructive CAD examined by CAG from 2003–2016 in Western Denmark and an age and sex matched comparison group, sampled from the general population in Western Denmark without previous history of coronary heart disease. Outcomes were MI, ischemic stroke, and death. The 10-year cumulative incidences were estimated. Adjusted hazard ratios (HRs) were estimated by stratified Cox regression using the general population as the reference group.

Results

We identified 5,760 diabetes patients without obstructive CAD and 29,139 individuals from the general population. Median follow-up was 7 years with 25% of participants followed for up to 10 years. Diabetes patients without obstructive CAD had an almost similar 10-year risk of MI (3.2% vs 2.9%, adjusted HR 0.91, 95% CI 0.70–1.17, Figure) compared to the general population cohort. Diabetes patients had an increased risk of ischemic stroke (5.2% vs 2.2%, adjusted HR 1.88, 95% CI 1.48–2.39), and death (29.7% vs 17.9%, adjusted HR 1.41, 95% CI 1.29–1.54). The duration of diabetes was associated with increased cardiovascular risk.

Conclusions

Absence of obstructive CAD by CAG in patients with diabetes ensures a low MI risk similar to the general population, but diabetes patients still have an increased risk of ischemic stroke and all-cause death despite absence of CAD.

Figure 1

Funding Acknowledgement

Type of funding source: Public hospital(s). Main funding source(s): Department of Cardiology, Aarhus University Hospital

Risk of lower limb amputation in diabetes patients with and without coronary artery disease – a cohort study from Western Denmark

Background

Diabetes patients are at greater risk of lower limb amputation due to a higher risk of peripheral artery disease (PAD) and peripheral neuropathy. The effect of concomitant coronary artery disease (CAD) is less explored.

Purpose

We examined the risk of PAD, lower limb revascularization, and lower limb amputation in diabetes and non-diabetes patients with and without CAD examined by coronary angiography.

Methods

We included all patients who underwent coronary angiography between 2003–2016 in Western Denmark. Patients with a history of PAD or previous lower limb revascularization or amputation were excluded. Patients were stratified by diabetes and CAD status and followed in prospective registries for a maximum of 10 years. Outcomes were PAD, lower limb revascularization, and lower limb amputation. We estimated 10-year cumulative incidence and adjusted hazard ratios (aHR) using patients with neither diabetes nor CAD as reference. We also examined the effect of CAD extent, insulin treatment, and duration of diabetes in the diabetes group.

Results

A total of 118,787 coronary angiography patients were included of whom 17,482 (14.7%) had diabetes. Median follow-up was 6.8 years. Patients with both diabetes and CAD had the highest risk of PAD (aHR 3.90, 95% CI 3.55–4.28), lower limb revascularization (aHR 4.61, 95% CI 3.85–5.52), and lower limb amputation (aHR 9.49, 95% CI 7.27–12.39), compared with patients with neither diabetes nor CAD. Extent of CAD, insulin treatment, and duration of diabetes were all associated with increased risks of PAD and amputation in the diabetes group. CAD only patients had higher 10-year risk of PAD compared to diabetes only patients (7.9% versus 6.9%), but had lower risk of amputation (0.6% versus 2.4%, Figure). CAD only patients were most often amputated at hip/femur level, while diabetes only patients most often were amputated at ankle/foot/toe level.

Conclusions

Presence of CAD in patients with diabetes was an indicator of high risk of PAD and lower limb amputation, and the risk depended on severity of both CAD and diabetes.

Figure 1

Funding Acknowledgement

Type of funding source: Public hospital(s). Main funding source(s): Department of Cardiology, Aarhus University Hospital

Influence of Plaque Characteristics on Early Vascular Healing in Patients With ST-Elevation Myocardial Infarction

OBJECTIVES

To compare the early vascular healing of ruptured plaques (RP) and non-ruptured plaques (NRP) one month after primary percutaneous coronary intervention (PCI) in patients with ST-segment elevation myocardial infarction (STEMI), using optical coherence tomography (OCT).

BACKGROUND

Vascular healing and strut coverage are important factors in reducing the risk of stent thrombosis after PCI. Influence of underlying lesion characteristics and differences in healing response between RP and NRP are unknown.

METHODS

Twenty-six STEMI-patients underwent PCI and implantation of a polymer-free drug-coated Biofreedom stent (BF-BES). OCT was performed pre-PCI, post-PCI and at 1-month follow-up. The patients were divided into two groups: RP = 15 and NRP = 11. OCT analyses of culprit lesion, post stent implantation at baseline and follow-up were performed to determine the difference in vascular healing based on presence of uncovered and/or malapposed stent struts and intraluminal filling defects.

RESULTS

The stent coverage did not differ significantly between the two groups at 1-month follow-up with percentage of uncovered struts: RP 26.5% [IQR 15.0-49.0] and NRP 28.1% [IQR 15.5-38.8] for NRP (p = 0.78). At 1-month, RP showed an increased percentage of late acquired malapposed struts (1.4% [IQR 0.8-2.4] vs. 0.0% [IQR 0.0-1.4], p = 0.03) and a larger total malapposition area (1.3 mm² [IQR 0.4-2.5] vs. 0.0 mm² [IQR 0.0-0.9], p = 0.01), compared to NRP.

CONCLUSION

Three out of four struts were covered within one month after stenting. The vascular healing was comparable in RP and NRP on stent coverage. However, RP had more and larger late acquired malapposition areas.

A Novel Model for Prediction of Thromboembolic and Cardiovascular Events in Patients Without Atrial Fibrillation

Patients without atrial fibrillation (AF) constitute approximately 75% of patients suffering thromboembolism and major adverse cardiovascular events (MACE), but evidence supporting risk stratification in these patients is sparse. We aimed to develop a risk prediction model for identification of patients without AF at high risk of first-time thromboembolic events. We included 72,381 coronary angiography patients without AF and without previous ischemic stroke or transient ischemic attack. The cohort was randomly divided into a derivation cohort (80%, n = 57,680) and a validation cohort (20%, n = 14,701). The primary thromboembolic end point was a composite of ischemic stroke, transient ischemic attack, and systemic embolism. MACE was defined as a composite of cardiac death, myocardial infarction, and ischemic stroke. The final model was compared with 2 validated clinical risk models (CHADS₂ and CHA₂DS₂-VASc). The risk prediction model assigned 1 point to heart failure, hypertension, diabetes mellitus, renal disease, age 65 to 74 years, active smoking, and multivessel obstructive coronary artery disease, and 2 points to age ≥75 years and peripheral artery disease. A C-index of 0.66 (95% CI 0.64 to 0.69) for prediction of the composite thromboembolic end point was found in the validation cohort, which was higher than for CHADS₂ (C-index 0.63 [95% CI 0.60 to 0.67]; p < 0.001) and CHA₂DS₂-VASc (C-index 0.64 [95% CI 0.62 to 0.67]; p = 0.034). The model also predicted MACE (C-index 0.71 [95% CI 0.69 to 0.73]). In conclusion it is possible to identify patients without AF at high risk of first-time thromboembolic events and MACE by use of a simple clinical prediction model.

Agreement between nonculprit stenosis follow-up iFR and FFR after STEMI (iSTEMI substudy)

Objective

To evaluate agreement between instantaneous wave free ratio (iFR) and fractional flow reserve (FFR) for the functional assessment of nonculprit coronary stenoses at staged follow-up after ST-segment elevation myocardial infarction (STEMI).

Results

We measured iFR and FFR at staged follow-up in 112 STEMI patients with 146 nonculprit stenoses. Median interval between STEMI and follow-up was 16 (interquartile range 5–32) days. Agreement between iFR and FFR was 77% < 5 days after STEMI and 86% after ≥ 5 days (p = 0.19). Among cases with disagreement, the proportion of cases with hemodynamically significant iFR and non-significant FFR were different when assessed < 5 days (5 in 8, 63%) versus ≥ 5 days (3 in 15, 20%) after STEMI (p = 0.04). Overall classification agreement between iFR and FFR was comparable to that observed in stable patients. Time interval between STEMI and follow-up evaluation may impact agreement between iFR and FFR.

Diabetes is not a risk factor for myocardial infarction in patients without coronary artery disease: A study from the Western Denmark Heart Registry

BACKGROUND

Diabetes is considered a risk factor for myocardial infarction. However, we have previously found that diabetes was not a short-term risk factor for myocardial infarction in the absence of obstructive coronary artery disease.

METHODS

We conducted a cohort study of patients undergoing coronary angiography from 2003 to 2012 and followed them by cross-linking Danish health registries. Patients were stratified according to coronary artery disease and diabetes. Endpoints included myocardial infarction, cardiac death, all-cause death and coronary revascularization.

RESULTS

86,202 patients were included in total (diabetes: n = 12,652). Median follow-up was 8.8 years. Using patients with neither coronary artery disease nor diabetes as reference (cumulative myocardial infarction incidence 2.6%), the risk of myocardial infarction was low and not substantially increased for patients with diabetes alone (3.2%; hazard ratio 1.202, 95% confidence interval 0.996-1.451), was increased for patients with coronary artery disease alone (9.3%; hazard ratio 2.75, 95% confidence interval 2.52-3.01) and was highest for patients with both coronary artery disease and diabetes (12.3%; hazard ratio 3.79, 95% confidence interval 3.43-4.20). Similar associations were observed for cardiac death and coronary revascularization.

CONCLUSION

Diabetes patients without coronary artery disease by coronary angiography have a low risk of myocardial infarction, not substantially increased compared to patients with neither coronary artery disease nor diabetes. In the presence of coronary artery disease, however, diabetes increases the risk of myocardial infarction.

Randomized Comparison of the Polymer-Free Biolimus-Coated BioFreedom Stent With the Ultrathin Strut Biodegradable Polymer Sirolimus-Eluting Orsiro Stent in an All-Comers Population Treated With Percutaneous Coronary Intervention

Background:

In patients with increased bleeding risk, the biolimus A9-coated BioFreedom stent, a stainless steel drug-coated stent free from polymer, has shown superiority compared with a bare-metal stent. The aim of this study was to investigate whether the BioFreedom stent is noninferior to a modern ultrathin strut biodegradable polymer cobalt-chromium sirolimus-eluting Orsiro stent in an all-comers patient population treated with percutaneous coronary intervention.

Methods:

The SORT OUT IX trial (Scandinavian Organization for Randomized Trials With Clinical Outcome IX), was a large-scale, registry-based, randomized, multicenter, single-blind, 2-arm, noninferiority trial. The primary end point, major adverse cardiovascular events, was defined as the composite of cardiac death, myocardial infarction not related to any segment other than the target lesion, or target lesion revascularization within 1 year, analyzed by intention-to-treat. The trial was powered to assess noninferiority for major adverse cardiovascular events of the BioFreedom stent compared with the Orsiro stent with a predetermined noninferiority margin of 0.021.

Results:

Between December 14, 2015 and April 21, 2017, 3151 patients were assigned to treatment with the BioFreedom stent (1572 patients, 1966 lesions) or to the Orsiro stent (1579 patients, 1985 lesions). Five patients were lost to follow-up because of emigration (99.9% follow-up rate). Mean age was 66.3±10.9, diabetes mellitus was seen in 19.3% of patients, and 53% of the patients had acute coronary syndromes. At 1 year, intention-to-treat analysis showed that 79 (5.0%) patients, who were assigned the BioFreedom stent, and 59 (3.7%), who were assigned the Orsiro stent, met the primary end point (absolute risk difference 1.29% [upper limit of one-sided 95% CI 2.50%]; P noni nferiority =0.14). Significantly more patients in the BioFreedom stent group had target lesion revascularization than those in the Orsiro stent group (55 [3.5%] vs 20 [1.3%], rate ratio 2.77 [95% CI, 1.66–4.62]; P <0.0001).

Conclusions:

The biolimus A9-coated BioFreedom polymer-free stent did not meet criteria for noninferiority for major adverse cardiovascular events at 12 months when compared with the ultrathin strut biodegradable polymer sirolimus-eluting Orsiro stent in an all-comers population

Registration:

URL: https://www.clinicaltrials.gov ; Unique identifier: NCT02623140.

Platelet aggregation and response to aspirin therapy in cardiac allograft vasculopathy

BACKGROUND

Long-term survival after heart transplantation (HTx) is compromised by cardiac allograft vasculopathy (CAV) characterized by coronary macro- and microvascular disease. The pathogenesis of CAV is unclear and may involve coronary thrombosis. We investigated whether HTx patients with CAV had higher platelet aggregation and turnover than HTx patients without CAV and healthy controls. Furthermore, we investigated the anti-platelet effect of low-dose aspirin in HTx patients.

METHODS

We included 57 patients who had undergone HTx (median 8.3 years from HTx) and 57 healthy controls. Platelet aggregation was measured on-aspirin and off-aspirin using impedance aggregometry with adenosine diphosphate (ADP) and arachidonic acid (AA). We evaluated platelet turnover by flow cytometry, CAV burden by coronary angiography and echocardiography, and microvascular function by echocardiographic coronary flow velocity reserve (CFVR).

RESULTS

Off-aspirin, HTx patients with CAV (n = 21) had higher ADP-induced platelet aggregation than healthy controls (p < 0.01) and HTx patients without CAV (n = 36) (p < 0.05). Aspirin treatment reduced AA-induced platelet aggregation in both HTx groups, but HTx patients with CAV had higher platelet aggregation on-aspirin than HTx patients without CAV (p < 0.05). Platelet turnover did not differ between HTx patients with CAV and HTx patients without CAV (p > 0.34). HTx patients with lower CFVR values had higher platelet aggregation than HTx patients with higher CFVR values (p < 0.05).

CONCLUSIONS

Off-aspirin, platelet aggregation was higher in HTx patients with CAV than in HTx patients without CAV and healthy controls. On-aspirin, platelet aggregation was higher in HTx patients with CAV than in HTx patients without CAV. Aspirin monotherapy may not provide sufficient platelet inhibition in HTx patients with CAV.

Diabetes Mellitus Is Associated With Increased Risk of Ischemic Stroke in Patients With and Without Coronary Artery Disease

Background and Purpose- Diabetes mellitus (DM) and non-DM patients without coronary artery disease (CAD) have a similar low risk of myocardial infarction after coronary angiography. The risk of ischemic stroke in DM patients dependent on CAD status is less explored. We examined whether DM patients without CAD have a risk of ischemic stroke similar to that in patients with neither DM nor CAD. Methods- We conducted a cohort study of patients who underwent coronary angiography between 2004 and 2012 in Western Denmark. Patients diagnosed with previous ischemic stroke or transient ischemic attack were excluded. Patients were stratified according to the presence of DM and CAD. Follow-up started 30 days after coronary angiography. We computed event rates and adjusted incidence rate ratios using patients without DM or CAD as reference. We examined the trend between CAD extent and ischemic stroke in patients with DM. Results- A total of 81 909 patients were included. Median follow-up was 3.8 years. Patients with both DM and CAD were at the highest risk of ischemic stroke (1.32 events per 100 person-years; adjusted incidence rate ratio, 2.00 [95% CI, 1.72-2.32]). Patients with CAD alone (0.77 events per 100 person-years; adjusted incidence rate ratio, 1.27 [95% CI, 1.12-1.44]) or DM alone (0.95 events per 100 person-years; adjusted incidence rate ratio, 1.74 [95% CI, 1.42-2.15]) were at intermediate risk, whereas patients with neither DM nor CAD (0.52 events per 100 person-years) were at the lowest risk. Among patients with DM, extent of CAD was further predictive of risk (P_trend<0.001). Conclusions- Not only CAD but also DM are associated with the risk of ischemic stroke after coronary angiography. Their combination further increases the risk of ischemic stroke depending on the extent of CAD.

287Diabetes mellitus is a risk factor for ischemic stroke in patients with and without coronary artery disease after coronary angiography

Background

Diabetes (DM) and non-DM patients without coronary artery disease (CAD) by coronary angiography (CAG) have the same low risk of myocardial infarction.

Purpose

To study whether DM patients without CAD have the same risk of ischemic stroke as patients with neither DM nor CAD.

Methods

We conducted a cohort study of patients, who underwent CAG between 2004 and 2012 in the Western Denmark Heart Registry. Patients previously diagnosed with ischemic stroke or atrial fibrillation (AF) and those treated with an oral anticoagulant were excluded. Patients were stratified according to presence of DM and CAD. Follow-up started 30 days after CAG. We computed event rates and adjusted incidence rate ratios (IRRs) using patients with neither DM nor CAD as reference.

Results

A total of 68,829 patients were included. Median follow-up was 4.0 years. Patients with both DM and CAD were at the highest risk of ischemic stroke (1.25 events per 100 person-years; adjusted IRR 2.10, 95% CI 1.77–2.48) (Figure 1). Patients with CAD alone (0.70 events per 100 person-years; adjusted IRR 1.29, 95% CI 1.12–1.48) or DM alone (0.84 events per 100 person-years; adjusted IRR 1.79, 95% CI 1.41–2.26) were at intermediate risk while patients with neither DM nor CAD (0.46 events per 100 person-years) were at lowest risk. Among DM patients, extent of CAD was further predictive of risk (ptrend<0.001).

Figure 1

Conclusions

Not only CAD but also DM independently predict the risk of ischemic stroke after CAG. Their combination further increases the risk of ischemic stroke depending on the extent of CAD.

P1527The applicability of the dual pathway approach criteria after coronary angiography

Background

The combination of aspirin and low-dose rivaroxaban (dual pathway approach, DPA) has been approved for high-risk patients with stable coronary artery disease (CAD) in the COMPASS trial. Patients with CAD combined with ≥1 DPA criteria, defined as peripheral artery disease, renal failure, heart failure, or diabetes, have been proposed as high-risk patients eligible for DPA.

Purpose

To determine the prevalence of patients meeting the DPA criteria and the association with major adverse cardiovascular events (MACE) in patients with stable CAD after coronary angiography (CAG). Further, to evaluate use of the DPA criteria in CAD patients meeting the inclusion criteria in the COMPASS trial.

Methods

We studied patients included in the Western Denmark Heart Registry after examination by CAD 2004–11. Patients without CAD or myocardial infarction (MI) <1 year before or 30 days after CAG were excluded. Patients were stratified according to 0 or ≥1 DPA criteria and being eligible/ineligible for the COMPASS trial. Event rates and incidence rate ratios (IRRs) of MACE (cardiac death, ischemic stroke, and MI) were estimated.

Results

Of 80,071 patients undergoing CAG, 18,689 (23%) patients had stable CAD. According to the DPA criteria, 7,730 patients (10%) were DPA eligible. Rates of MACE were 1.98 (95% CI 1.86–2.34) events per 100 person-years among DPA ineligible patients and 4.26 (95% CI 4.04–4.50) events per 100 person-years among DPA eligible patients (IRR 2.15, 95% CI 1.98–2.34). When stratifying patients according to eligibility in the COMPASS inclusion criteria, COMPASS eligible patients with 0 DPA criteria and COMPASS ineligible patients with ≥1 DPA criteria were at intermediate risk compared to patients meeting both (high risk) or none (low risk) of these criteria (Figure 1).

Figure 1

Conclusion

In a cohort of consecutive patients undergoing CAG, 1 in 10 patients would be eligible for DPA according to the DPA criteria. Patients with stable CAD and ≥1 DPA criteria had >2-fold higher rate of MACE than CAD patients without any DPA criteria.

Everolimus-Eluting Versus Biolimus-Eluting Coronary Stent Implantation in Patients With and Without Diabetes Mellitus

Diabetes mellitus is associated with a higher risk of target lesion revascularization after percutaneous coronary intervention. We compared clinical outcomes in patients with and without diabetes mellitus, treated with everolimus-eluting stents (EES; Synergy; Boston Scientific, Marlborough, Massachusetts) or biolimus-eluting stents (BES; BioMatrix NeoFlex; Biosensors Interventional Technologies Pte Ltd., Singapore). In total, 2,764 patients were randomized to stent implantation with EES (n = 1,385, diabetes: n = 250) or the BES (n = 1,379, diabetes: n = 262), stratified by gender and diabetes. The primary end point, target lesion failure (TLF), was a composite of cardiac death, target-lesion myocardial infarction, or target lesion revascularization at 12 months. Secondary end points included individual components of TLF, all-cause death, and stent thrombosis. TLF was 2.1% lower in the EES versus the BES groups in patients with diabetes (3.6% vs 5.7%; rate ratios 0.61, 95% confidence interval [CI] 0.27 to 1.41) and similar in patients without diabetes (4.1% vs 4.0%; rate ratios 0.99, 95% CI 0.66 to 1.51). In patients with diabetes, the point estimates of the individual components of TLF also favored the EES but CIs were wide. No interaction between stent type and presence of diabetes was found. The current subgroup analysis found that a thin-strut EES as compared with a thicker strut BES had a numerically lower TLF rate in patients with diabetes, but the subgroup analysis was underpowered for definite conclusions.

Association between anti-diabetes treatments and cardiovascular risk in diabetes patients with and without coronary artery disease

OBJECTIVE

We examined the risk of myocardial infarction associated with glucose-lowering therapy among diabetes patients with and without obstructive coronary artery disease.

METHODS

A cohort of patients with type 1 or type 2 diabetes (n = 12,030), who underwent coronary angiography from 2004 to 2012, were stratified by presence of obstructive (any stenosis ⩾50%) coronary artery disease and by type of diabetes treatment: diet, non-insulin treatment and insulin (±oral anti-diabetics). The primary endpoint was myocardial infarction. Adjusted hazard ratios were calculated using diet-treated patients without coronary artery disease as reference.

RESULTS

In patients without coronary artery disease, risk of myocardial infarction was similar in patients treated with non-insulin medication (adjusted hazard ratio 0.70, 95% confidence interval 0.27-1.81) and insulin (adjusted hazard ratio 0.76, 95% confidence interval 0.27-2.08) as compared to diet only. In patients with coronary artery disease, the risk of myocardial infarction was higher than in the reference group and an incremental risk was observed being lowest in patients treated with diet (adjusted hazard ratio 3.79, 95% confidence interval 1.61-8.88), followed by non-insulin medication (adjusted hazard ratio 5.42, 95% confidence interval 2.40-12.22), and highest in insulin-treated patients (adjusted hazard ratio 7.91, 95% confidence interval 3.51-17.82).

CONCLUSION

The presence of obstructive coronary artery disease defines the risk of myocardial infarction in diabetes patients. Glucose-lowering therapy, in particular insulin, was associated with risk of myocardial infarction only in the presence of coronary artery disease.

Predicting stroke in patients without atrial fibrillation

BACKGROUND

Only few studies in selected cohorts have examined whether the CHA₂ DS₂ -VASc score can predict the risk of atrial fibrillation and thromboembolic events in patients without atrial fibrillation.

MATERIALS AND METHODS

Patients with coronary angiography performed between 2004 and 2012 were grouped according to CHA₂ DS₂ -VASc score. We excluded patients with atrial fibrillation, anticoagulant therapy and follow-up <30 days. The endpoints were atrial fibrillation and a composite of ischaemic stroke, transient ischaemic attack and systemic embolism. Event rates per 100 person-years were estimated for each CHA₂ DS₂ -VASc score (0, 1, 2, 3, 4, and >4). Incidence rate ratios were calculated using low-risk patients (CHA₂ DS₂ -VASc score 0 in males or 1 in females) as reference.

RESULTS

In total, 78 233 patients were included with group sizes varying between 8299 (CHA₂ DS₂ -VASc >4) and 19 882 (CHA₂ DS₂ -VASc 2). An increasing CHA₂ DS₂ -VASc score was significantly associated with a future diagnosis of atrial fibrillation (P for trend <0.0001) and an incremental risk of ischaemic stroke, transient ischaemic attack, systemic embolism (P for trend <0.0001) and all-cause death (P for trend <0.0001). Patients with a CHA₂ DS₂ -VASc score of 3 had a rate of ischaemic stroke/transient ischaemic attack/systemic embolism of 1.30 per 100 person-years.

CONCLUSIONS

Among patients undergoing coronary angiography, the CHA₂ DS₂ -VASc score predicted a future diagnosis of atrial fibrillation and the composite risk of ischaemic stroke, transient ischaemic attack or systemic embolism in patients without atrial fibrillation. A CHA₂ DS₂ -VASc score of 3 was associated with a risk that would justify prophylactic oral anticoagulation treatment in a patient with atrial fibrillation.

Extent of coronary artery disease is associated with myocardial infarction and mortality in patients with diabetes mellitus

Purpose: We examined risk of myocardial infarction and all-cause death associated with the extent of coronary artery disease ascertained by coronary angiography in patients with diabetes mellitus. We hypothesized that risks of myocardial infarction and death were associated with extent of coronary artery disease in diabetes patients.

Patients and methods: We conducted a cohort study of patients with type 1 and type 2 diabetes, who underwent coronary angiography from 2004 to 2012. Patients were stratified according to extent of coronary artery disease: 0-, 1-, 2- or 3-vessel disease or diffuse vessel disease. Endpoints were myocardial infarction, all-cause death, and major adverse cardiovascular events (MACE), defined as the composite of myocardial infarction, cardiac death, or ischemic stroke. Adjusted incidence and mortality rate ratios (IRRs_adj) were calculated using patients with 0-vessel disease as the reference group. Median follow-up was 3 years for a total of 45,164 person-years.

Results: The study included 12,594 diabetes patients. Of these, 3,147 (25.0%) had 0-vessel disease, 1,195 (9.5%) had diffuse vessel disease, 3,001 (23.8%) had 1-vessel disease, 2,220 (17.6%) had 2-vessel disease, and 3,031 (24.1%) had 3-vessel disease. The myocardial infarction rate was 0.4 per 100 person-years (95% CI: 0.3–0.5) in patients with 0-vessel disease. Using patients with 0-vessel disease as reference, the risk of myocardial infarction increased according to the number of diseased vessels (diffuse vessel disease: 1.4 per 100 person-years, IRR_adj 3.87, 95% CI: 2.41–6.23; 1-vessel disease: 1.9 per 100 person-years, IRR_adj 4.99, 95% CI: 3.33–7.46; 2-vessel disease: 2.7 per 100 person-years, IRR_adj 7.14, 95% CI: 4.78–10.65; and 3-vessel disease: 4.3 per 100 person-years, IRR_adj 11.42, 95% CI: 7.76–16.82; p_trend<0.001). Similar associations were observed for all-cause death and MACE.

Conclusion: The extent of coronary artery disease is a major risk factor for myocardial infarction and death in patients with diabetes mellitus.

External applicability of the COMPASS trial: the Western Denmark Heart Registry

Aims

In the COMPASS trial, combined aspirin and rivaroxaban treatment reduced ischaemic events in patients with stable coronary artery disease (CAD) or peripheral artery disease (PAD). We estimated the proportion of COMPASS eligible patients among unselected patients undergoing coronary angiography (CAG) and compared outcome rates among COMPASS eligible and non-eligible patients.

Methods and results

We applied the COMPASS study criteria on patients undergoing CAG in Western Denmark (2004–11). Both COMPASS eligible and non-eligible patients had CAD/PAD and met no exclusion criteria, but only COMPASS eligible patients met the inclusion criteria. We assessed the COMPASS primary endpoint of cardiovascular death, ischaemic stroke, haemorrhagic stroke, or myocardial infarction (MI). We computed event rates and adjusted incidence rate ratios (aIRRs). Of 80 071 patients undergoing CAG, 27 939 did not have CAD or PAD and were not considered. Of the 52 132 patients remaining, 11 930 were COMPASS eligible. Rates of the primary endpoint were 4.8 (95% confidence interval 4.6–5.0) events per 100 person-years among COMPASS eligible patients and 2.3 (2.2–2.4) among COMPASS non-eligible patients [aIRR 1.7 (1.6–1.9)]. COMPASS eligible patients also had higher risks of cardiovascular death [aIRR 2.5 (2.1–3.0)], ischaemic stroke [aIRR 1.4 (1.2–1.6)], and MI [aIRR 1.9 (1.7–2.1)].

Conclusion

In this all-comers CAG cohort, 15% were eligible for combined aspirin and rivaroxaban treatment. COMPASS eligible patients had up to 2.5-fold higher rates of cardiovascular events than non-eligible patients. The higher incidence of ischaemic events in COMPASS eligible patients highlights an unmet need for additional preventive measures.

Validation of the European Society of Cardiology and European Society of Anaesthesiology non-cardiac surgery risk score in patients treated with coronary drug-eluting stent implantation

Aims

The current guidelines from the European Society of Cardiology and European Society of Anaesthesiology on non-cardiac surgery (ESC/ESA-NCS) divide surgical procedures into those associated with low risk (<1%), intermediate risk (1-5%), and high risk (>5%) of major adverse cardiac events (MACE). Evaluating surgical risk might be particularly appropriate in patients with recent stent implantation, and thus we validated the ESC/ESA-NCS classification in patients undergoing NCS within 1 year after coronary drug-eluting stent (DES) implantation.

Methods and results

By record-linking the Western Denmark Heart Registry and the Danish National Patient Registry, we identified 4046 patients, who underwent NCS between 1 and 12 months after DES implantation. Primary outcomes were MACE [cardiac death and myocardial infarction (MI)] and a combined endpoint of mortality and MI within 30 days after surgery. Both MACE (low risk 0.6%, intermediate risk 1.2%, and high risk 3.4%) and the combined endpoint of mortality and MI (1.5%, 4.6%, and 14.9%) were associated with the ESC/ESA-NCS classification. As compared with low-risk surgery, the odds ratios (OR) for MACE were 1.9 [95% confidence interval (CI) 0.9-4.1] for intermediate-risk surgery and 5.8 (95% CI 1.7-20.1) for high-risk surgery. For the combined endpoint of mortality and MI, the OR's were 3.1 (95% CI 2.1-4.7) for intermediate-risk surgery and 11.3 (95% CI 5.9-21.9) for high-risk surgery.

Conclusion

The ESC/ESA-NCS classification is a valid tool to predict the risk of both MACE and the combined endpoint of mortality and MI for patients undergoing NCS.

Computed tomography derived fractional flow reserve testing in stable patients with typical angina pectoris: influence on downstream rate of invasive coronary angiography

Aims

To assess the use of downstream coronary angiography (ICA) and short-term safety of frontline coronary CT angiography (CTA) with selective CT-derived fractional flow reserve (FFR_CT) testing in stable patients with typical angina pectoris.

Methods and results

Between 1 January 2016 and 30 June 2016 all patients (N = 774) referred to non-emergent ICA or coronary CTA at Aarhus University Hospital on a suspicion of CAD had frontline CTA performed. Downstream testing and treatment within 3 months and adverse events ≥90 days were registered. Patients were divided into two groups according to the presence of typical angina pectoris, which according to local practice would have resulted in referral to ICA, (low-intermediate-risk, n = 593 [76%]; high-risk, n = 181 [24%]) with mean pre-test probability of CAD of 31 ± 16% and 67 ± 16%, respectively. Coronary CTA was performed in 745 (96%) patients in whom FFR_CT was prescribed in 212 (28%) patients. In the high- vs. low-intermediate-risk group, ICA was cancelled in 75% vs. 91%. Coronary revascularization was performed more frequently in high-risk than in low-intermediate-risk patients, 76% vs. 52% (P = 0.03). Mean follow-up time was 157 ± 50 days. Serious clinical events occurred in four patients, but not in any patients with cancelled ICA by coronary CTA with selective FFR_CT testing.

Conclusion

Frontline coronary CTA with selective FFR_CT testing in stable patients with typical angina pectoris in real-world practice is associated with a high rate of safe cancellation of planned ICAs.