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Belyayev L, Stock EM, Hattler B, Bakaeen FG, Kinlay S, Quin JA, Haime M, Biswas K, Zenati MA. Complete Coronary Revascularization and Outcomes in Patients Who Underwent Coronary Artery Bypass Grafting: Insights from The REGROUP Trial. Am J Cardiol 2024; 217:127-135. [PMID: 38266796 DOI: 10.1016/j.amjcard.2024.01.015] [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: 10/01/2023] [Revised: 12/19/2023] [Accepted: 01/15/2024] [Indexed: 01/26/2024]
Abstract
There is growing evidence in support of coronary complete revascularization (CR). Nonetheless, there is no universally accepted definition of CR in patients who undergo coronary bypass grafting surgery (CABG). We sought to investigate the outcomes of CR, defined as surgical revascularization of any territory supplied by a suitable coronary artery with ≥50% stenosis. We performed a preplanned subanalysis in the Randomized Trial of Endoscopic or Open Saphenous Vein Graft Harvesting (REGROUP) clinical trial cohort. Of 1,147 patients who underwent CABG, 810 (70.6%) received CR. The primary outcome was a composite of major adverse cardiac events (MACEs), including death from any cause, nonfatal myocardial infarction, or repeat revascularization over a median 4.7 years of follow-up. MACE occurred in 175 patients (21.6%) in the CR group and 86 patients (25.5%) in the incomplete revascularization (IR) group (hazard ratio [HR] 0.87, 95% confidence interval [CI] 0.67 to 1.13, p = 0.29). A total of 97 patients (12.0%) in the CR group and 48 patients (14.2%) in the IR group died (HR 0.93, 95% CI 0.65 to 1.32, p = 0.67); nonfatal myocardial infarction occurred in 49 patients (6.0%) in the CR group and 30 patients (8.9%) in the IR group (HR 0.76, 95% CI 0.48 to 1.2, p = 0.24), and repeat revascularization occurred in 62 patients (7.7%) in the CR group and 39 patients (11.6%) in the IR group (HR 0.64; 95% CI 0.42 to 0.95, p = 0.027). In conclusion, in patients with a great burden of co-morbidities who underwent CABG in the REGROUP trial over a median follow-up period of a median 4.7 years, CR was associated with similar MACE rates but a reduced risk of repeat revascularization. Longer-term follow-up is warranted.
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Affiliation(s)
- Leonid Belyayev
- Division of Thoracic and Cardiac Surgery, Brigham and Women's Hospital, Boston, Massachusetts.
| | - Eileen M Stock
- Cooperative Studies Program Coordinating Center, Office of Research and Development, US Department of Veterans Affairs, Perry Point, Maryland
| | - Brack Hattler
- Division of Cardiology, Eastern Colorado Veterans Affairs Healthcare System and University of Colorado, Aurora, Colorado
| | - Faisal G Bakaeen
- Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio
| | - Scott Kinlay
- Divisions of Cardiology, Veterans Affairs Boston Healthcare System, and Harvard Medical School, Boston, Massachusetts
| | - Jacqueline A Quin
- Cardiac Surgery, Veterans Affairs Boston Healthcare System, and Harvard Medical School, Boston, Massachusetts
| | - Miguel Haime
- Cardiac Surgery, Veterans Affairs Boston Healthcare System, and Harvard Medical School, Boston, Massachusetts
| | - Kousick Biswas
- Cooperative Studies Program Coordinating Center, Office of Research and Development, US Department of Veterans Affairs, Perry Point, Maryland
| | - Marco A Zenati
- Division of Thoracic and Cardiac Surgery, Brigham and Women's Hospital, Boston, Massachusetts; Cardiac Surgery, Veterans Affairs Boston Healthcare System, and Harvard Medical School, Boston, Massachusetts
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Ali ZA, Garcia JJ, Karimi Galougahi K, Horst J, Gallo A, Shin D, Ben-Yehuda O, Chen S, Redfors B, Kappetein AP, Sabik JF, Serruys PW, Stone GW. Impact of In complete Revascularization After PCI in Left Main Disease: The EXCEL Trial. Circ Cardiovasc Interv 2024; 17:e013192. [PMID: 38502720 DOI: 10.1161/circinterventions.123.013192] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [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: 04/20/2023] [Accepted: 01/02/2024] [Indexed: 03/21/2024]
Abstract
BACKGROUND The importance of complete revascularization after percutaneous coronary intervention (PCI) in patients with left main coronary artery disease is uncertain. We investigated the clinical impact of complete revascularization in patients with left main coronary artery disease undergoing PCI in the EXCEL trial (Evaluation of XIENCE Versus Coronary Artery Bypass Surgery for Effectiveness of Left Main Revascularization). METHODS Composite rates of death or myocardial infarction (MI) following PCI during 5-year follow-up were examined in 903 patients based on core laboratory definitions of anatomic and functional complete revascularization, residual SYNTAX score (The Synergy Between Percutaneous Coronary Intervention With Taxus and Cardiac Surgery), and residual Jeopardy Score (rJS). RESULTS The risk of death or MI did not vary based on anatomic, functional, or residual SYNTAX score complete revascularization but did differ according to the rJS (5-year rates 17.6%, 19.5%, and 38.9% with rJS 0, 2, and ≥4, respectively; P=0.006). The higher rate of death or MI with rJS≥4 versus rJS≤2 was driven conjointly by increased mortality (adjusted hazard ratio, 2.29 [95% CI, 1.11-4.71]; P=0.02) and spontaneous MI (adjusted hazard ratio, 2.89 [95% CI, 1.17-7.17]; P=0.02). The most common location for untreated severe stenoses in the rJS≥4 group was the left circumflex artery (LCX), and the post-PCI absence, compared with the presence, of any untreated lesion with diameter stenosis ≥70% in the LCX was associated with reduced 5-year rates of death or MI (18.9% versus 35.2%; hazard ratio, 0.48 [95% CI, 0.32-0.74]; P<0.001). The risk was the highest for residual ostial/proximal LCX lesions. CONCLUSIONS Among patients undergoing PCI in EXCEL trial, incomplete revascularization according to the rJS was associated with increased rates of death and spontaneous MI. Post-PCI untreated high-grade lesions in the LCX (especially the ostial/proximal LCX) drove these outcomes. REGISTRATION URL: https://www.clinicaltrials.gov; Unique identifier: NCT01205776.
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Affiliation(s)
- Ziad A Ali
- Cardiovascular Research Foundation, New York, NY (Z.A.A., J.J.G., J.H., A.G., O.B.-Y., B.R.)
- St Francis Hospital and Heart Center, Roslyn, NY (Z.A.A., K.K.G., D.S.)
| | - Javier Jas Garcia
- Cardiovascular Research Foundation, New York, NY (Z.A.A., J.J.G., J.H., A.G., O.B.-Y., B.R.)
| | | | - Jennifer Horst
- Cardiovascular Research Foundation, New York, NY (Z.A.A., J.J.G., J.H., A.G., O.B.-Y., B.R.)
| | - Anthony Gallo
- Cardiovascular Research Foundation, New York, NY (Z.A.A., J.J.G., J.H., A.G., O.B.-Y., B.R.)
| | - Doosup Shin
- St Francis Hospital and Heart Center, Roslyn, NY (Z.A.A., K.K.G., D.S.)
| | - Ori Ben-Yehuda
- Cardiovascular Research Foundation, New York, NY (Z.A.A., J.J.G., J.H., A.G., O.B.-Y., B.R.)
| | - Shmuel Chen
- Weill-Cornell Medical Center/New York-Presbyterian Hospital, NY (S.C.)
| | - Björn Redfors
- Cardiovascular Research Foundation, New York, NY (Z.A.A., J.J.G., J.H., A.G., O.B.-Y., B.R.)
| | | | - Joseph F Sabik
- University Hospitals Cleveland Medical Center, OH (J.F.S.)
| | | | - Gregg W Stone
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY (G.W.S.)
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Manuca RD, Covic AM, Brinza C, Floria M, Statescu C, Covic A, Burlacu A. Updated Strategies in Non-Culprit Stenosis Management of Multivessel Coronary Disease-A Contemporary Review. Medicina (Kaunas) 2024; 60:263. [PMID: 38399550 PMCID: PMC10890538 DOI: 10.3390/medicina60020263] [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] [Subscribe] [Scholar Register] [Received: 12/15/2023] [Revised: 01/24/2024] [Accepted: 02/01/2024] [Indexed: 02/25/2024]
Abstract
The prevalence of multivessel coronary artery disease (CAD) in acute coronary syndrome (ACS) patients underscores the need for optimal revascularization strategies. The ongoing debate surrounding percutaneous coronary intervention (PCI), coronary artery bypass grafting (CABG), hybrid interventions, or medical-only management adds complexity to decision-making, particularly in specific angiographic scenarios. The article critically reviews existing literature, providing evidence-based perspectives on non-culprit lesion revascularization in ACS. Emphasis is placed on nuances such as the selection of revascularization methods, optimal timing for interventions, and the importance of achieving completeness in revascularization. The debate between culprit-only revascularization and complete revascularization is explored in detail, focusing on ST-elevation myocardial infarction (STEMI) and non-ST-elevation myocardial infarction (NSTEMI), including patients with cardiogenic shock. Myocardial revascularization guidelines and recent clinical trials support complete revascularization strategies, either during the index primary PCI or within a short timeframe following the culprit lesion PCI (in both STEMI and NSTEMI). The article also addresses the complexities of decision-making in NSTEMI patients with multivessel CAD, advocating for immediate multivessel PCI unless complex coronary lesions require a staged revascularization approach. Finally, the article provided contemporary data on chronic total occlusion revascularization in ACS patients, highlighting the prognostic impact. In conclusion, the article addresses the evolving challenges of managing multivessel CAD in ACS patients, enhancing thoughtful integration into the clinical practice of recent data. We provided evidence-based, individualized approaches to optimize short- and long-term outcomes. The ongoing refinement of clinical and interventional strategies for non-culprit lesion management remains dynamic, necessitating careful consideration of patient characteristics, coronary stenosis complexity, and clinical context.
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Affiliation(s)
- Rares-Dumitru Manuca
- Institute of Cardiovascular Diseases “Prof. Dr. George I.M. Georgescu”, 700503 Iasi, Romania; (R.-D.M.); (A.M.C.); (C.S.)
- Faculty of Medicine, University of Medicine and Pharmacy “Grigore T Popa”, 700115 Iasi, Romania; (M.F.); (A.C.)
| | - Alexandra Maria Covic
- Institute of Cardiovascular Diseases “Prof. Dr. George I.M. Georgescu”, 700503 Iasi, Romania; (R.-D.M.); (A.M.C.); (C.S.)
- Faculty of Medicine, University of Medicine and Pharmacy “Grigore T Popa”, 700115 Iasi, Romania; (M.F.); (A.C.)
| | - Crischentian Brinza
- Institute of Cardiovascular Diseases “Prof. Dr. George I.M. Georgescu”, 700503 Iasi, Romania; (R.-D.M.); (A.M.C.); (C.S.)
- Faculty of Medicine, University of Medicine and Pharmacy “Grigore T Popa”, 700115 Iasi, Romania; (M.F.); (A.C.)
| | - Mariana Floria
- Faculty of Medicine, University of Medicine and Pharmacy “Grigore T Popa”, 700115 Iasi, Romania; (M.F.); (A.C.)
- Internal Medicine Clinic, “St. Spiridon” County Clinical Emergency Hospital Iasi, 700111 Iasi, Romania
| | - Cristian Statescu
- Institute of Cardiovascular Diseases “Prof. Dr. George I.M. Georgescu”, 700503 Iasi, Romania; (R.-D.M.); (A.M.C.); (C.S.)
- Faculty of Medicine, University of Medicine and Pharmacy “Grigore T Popa”, 700115 Iasi, Romania; (M.F.); (A.C.)
| | - Adrian Covic
- Faculty of Medicine, University of Medicine and Pharmacy “Grigore T Popa”, 700115 Iasi, Romania; (M.F.); (A.C.)
- Nephrology Clinic, Dialysis, and Renal Transplant Center, “C.I. Parhon” University Hospital, 700503 Iasi, Romania
| | - Alexandru Burlacu
- Institute of Cardiovascular Diseases “Prof. Dr. George I.M. Georgescu”, 700503 Iasi, Romania; (R.-D.M.); (A.M.C.); (C.S.)
- Faculty of Medicine, University of Medicine and Pharmacy “Grigore T Popa”, 700115 Iasi, Romania; (M.F.); (A.C.)
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Spacek M, Vacha J, Kaminek M, Hutyra M, Nykl R, Sluka M, Taborsky M. Comparison of angiographic estimation and invasive hemodynamic measurement of the significance of non-infarct-related residual stenoses in ST-elevation myocardial infarction patients. Arch Med Sci Atheroscler Dis 2023; 8:e169-e176. [PMID: 38283928 PMCID: PMC10811533 DOI: 10.5114/amsad/172971] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2023] [Accepted: 09/27/2023] [Indexed: 01/30/2024] Open
Abstract
Introduction Up to 50% of patients with ST elevation myocardial infarction (STEMI) have ≥ 50% stenosis in a major non-infarct-related artery. Several studies have evaluated the prognostic value of the completion of revascularization with overall inconclusive results. Selection of the stenoses was based on the angiographic evaluation, invasive hemodynamic measurement or the combined approach. It is unknown whether such a selection provides correlation of comparable patient groups. Material and methods We enrolled 51 patients (62.7 ±10.2 years) with acute STEMI and at least one residual (50-90%) stenosis in a non-infarct-related major coronary artery (excluding left main coronary artery). Overall 65 stenoses (67.9 ±10.7%) were evaluated angiographically following primary percutaneous coronary intervention and the hemodynamic significance was estimated with respect to the stenosis severity, caliber of the arterial segment, localization of the stenosis (proximity) as well as the estimated size of the supplied vascular territory. During subsequent hospitalization, invasive measurement of the hemodynamic significance using fractional flow reserve (FFR) was performed to guide the final revascularization strategy (FFR value of ≤ 0.80 considered significant). Results Based on angiographic evaluation, a total of 44 stenoses would be recommended for treatment, whereas only 31 stenoses were revascularized based on FFR measurement. Moreover, visual evaluation and hemodynamic measurement were discrepant in 27 of 65 (41.5%) stenoses. Conclusions We observed a weak correlation between visual angiographic evaluation and invasive hemodynamic measurement. More stents would be implanted based on angiographic evaluation compared to FFR measurement.
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Affiliation(s)
- Miloslav Spacek
- Department of Internal Medicine I – Cardiology, Faculty of Medicine and Dentistry, Palacky University Olomouc and University Hospital Olomouc, Olomouc, Czech Republic
| | - Jan Vacha
- Department of Internal Medicine I – Cardiology, Faculty of Medicine and Dentistry, Palacky University Olomouc and University Hospital Olomouc, Olomouc, Czech Republic
| | - Milan Kaminek
- Department of Nuclear Medicine, Faculty of Medicine and Dentistry, Palacky University Olomouc and University Hospital Olomouc, Olomouc, Czech Republic
| | - Martin Hutyra
- Department of Internal Medicine I – Cardiology, Faculty of Medicine and Dentistry, Palacky University Olomouc and University Hospital Olomouc, Olomouc, Czech Republic
| | - Radomir Nykl
- Department of Internal Medicine I – Cardiology, Faculty of Medicine and Dentistry, Palacky University Olomouc and University Hospital Olomouc, Olomouc, Czech Republic
| | - Martin Sluka
- Department of Internal Medicine I – Cardiology, Faculty of Medicine and Dentistry, Palacky University Olomouc and University Hospital Olomouc, Olomouc, Czech Republic
| | - Milos Taborsky
- Department of Internal Medicine I – Cardiology, Faculty of Medicine and Dentistry, Palacky University Olomouc and University Hospital Olomouc, Olomouc, Czech Republic
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Lee SH, Hong D, Shin D, Kim HK, Park KH, Choo EH, Kim CJ, Kim MC, Hong YJ, Ahn SG, Doh JH, Lee SY, Park SD, Lee HJ, Kang MG, Koh JS, Cho YK, Nam CW, Joh HS, Choi KH, Park TK, Yang JH, Song YB, Choi SH, Jeong MH, Gwon HC, Hahn JY, Lee JM. QFR Assessment and Prognosis After Nonculprit PCI in Patients With Acute Myocardial Infarction. JACC Cardiovasc Interv 2023; 16:2365-2379. [PMID: 37821181 DOI: 10.1016/j.jcin.2023.08.032] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2023] [Revised: 07/13/2023] [Accepted: 08/01/2023] [Indexed: 10/13/2023]
Abstract
BACKGROUND Complete revascularization using either angiography-guided or fractional flow reserve (FFR)-guided strategy can improve clinical outcomes in patients with acute myocardial infarction (AMI) and multivessel disease. However, there is concern that angiography-guided percutaneous coronary intervention (PCI) may result in un-necessary PCI of the non-infarct-related artery (non-IRA), and its long-term prognosis is still unclear. OBJECTIVES This study sought to evaluate clinical outcomes after non-IRA PCI according to the quantitative flow ratio (QFR). METHODS We performed post hoc QFR analysis of non-IRA lesions of AMI patients enrolled in the FRAME-AMI (FFR Versus Angiography-Guided Strategy for Management of AMI With Multivessel Disease) trial, which randomly allocated 562 patients into either FFR-guided PCI (FFR ≤0.80) or angiography-guided PCI (diameter stenosis >50%) for non-IRA lesions. Patients were classified by non-IRA QFR values into the QFR ≤0.80 and QFR >0.80 groups. The primary outcome was a major adverse cardiac event (MACE), a composite of cardiac death, myocardial infarction, and repeat revascularization. RESULTS A total of 443 patients (552 lesions) were eligible for QFR analysis. Of 209 patients in the angiography-guided PCI group, 30.0% (n = 60) underwent non-IRA PCI despite having QFR >0.80 in the non-IRA. Conversely, only 2.7% (n = 4) among 209 patients in the FFR-guided PCI group had QFR >0.80 in the non-IRA. At a median follow-up of 3.5 years, the rate of MACEs was significantly higher among patients with non-IRA PCI despite QFR >0.80 than in patients with deferred PCI for non-IRA lesions (12.9% vs 3.1%; HR: 4.13; 95% CI: 1.10-15.57; P = 0.036). Non-IRA PCI despite QFR >0.80 was associated with a higher risk of non-IRA MACEs than patients with deferred PCI for non-IRA lesions (12.9% vs 2.1%; HR: 5.44; 95% CI: 1.13-26.19; P = 0.035). CONCLUSIONS In AMI patients with multivessel disease, 30.0% of angiography-guided PCI resulted in un-necessary PCI for the non-IRA with QFR >0.80, which was significantly associated with an increased risk of MACEs than in those with deferred PCI for non-IRA lesions. (FFR Versus Angiography-Guided Strategy for Management of AMI With Multivessel Disease [FRAME-AMI] ClinicalTrials.gov number; NCT02715518).
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Affiliation(s)
- Seung Hun Lee
- Division of Cardiology, Department of Internal Medicine, Heart Center, Chonnam National University Hospital, Chonnam National University Medical School, Gwangju, South Korea
| | - David Hong
- Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Doosup Shin
- Division of Cardiology, Department of Internal Medicine, Duke University Medical Center, Durham, North Carolina, USA
| | - Hyun Kuk Kim
- Chosun University Hospital, University of Chosun College of Medicine, Gwangju, Korea
| | - Keun Ho Park
- Chosun University Hospital, University of Chosun College of Medicine, Gwangju, Korea
| | - Eun Ho Choo
- Seoul St. Mary's Hospital, The Catholic University of Korea, Seoul, South Korea
| | - Chan Joon Kim
- The Catholic University of Korea, Uijeongbu St. Mary's Hospital, Seoul, Korea
| | - Min Chul Kim
- Division of Cardiology, Department of Internal Medicine, Heart Center, Chonnam National University Hospital, Chonnam National University Medical School, Gwangju, South Korea
| | - Young Joon Hong
- Division of Cardiology, Department of Internal Medicine, Heart Center, Chonnam National University Hospital, Chonnam National University Medical School, Gwangju, South Korea
| | - Sung Gyun Ahn
- Yonsei University Wonju College of Medicine, Wonju Severance Christian Hospital, Wonju, Korea
| | - Joon-Hyung Doh
- Department of Medicine, Inje University Ilsan Paik Hospital, Goyang, Korea
| | - Sang Yeub Lee
- Chung-Ang University College of Medicine, Chung-Ang University Gwangmyeong Hospital, Gwangmyeong, Korea
| | | | | | - Min Gyu Kang
- Gyeongsang National University School of Medicine, Gyeongsang National University Hospital, Jinju, Korea
| | - Jin-Sin Koh
- Gyeongsang National University School of Medicine, Gyeongsang National University Hospital, Jinju, Korea
| | - Yun-Kyeong Cho
- Keimyung University Dongsan Medical Center, Daegu, Korea
| | - Chang-Wook Nam
- Keimyung University Dongsan Medical Center, Daegu, Korea
| | - Hyun Sung Joh
- Seoul National University Boramae Medical Center, Seoul National University College of Medicine, Seoul, Korea
| | - Ki Hong Choi
- Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Taek Kyu Park
- Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Jeong Hoon Yang
- Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Young Bin Song
- Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Seung-Hyuk Choi
- Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Myung Ho Jeong
- Division of Cardiology, Department of Internal Medicine, Heart Center, Chonnam National University Hospital, Chonnam National University Medical School, Gwangju, South Korea
| | - Hyeon-Cheol Gwon
- Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Joo-Yong Hahn
- Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Joo Myung Lee
- Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea.
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Liu J, Zhang K, Wang X, Liu Z, Chen M, Fan F, Jia J, Hong T, Li J, Huo Y, Gong Y, Zheng B. Complete revascularization based on angiography derived fractional flow reserve versus incomplete revascularization in patients with ST-segment elevation myocardial infarction. Cardiol J 2023; 31:226-234. [PMID: 37772351 DOI: 10.5603/cj.92762] [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] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Revised: 07/29/2023] [Accepted: 08/09/2023] [Indexed: 09/30/2023] Open
Abstract
BACKGROUND Nearly half of ST-segment elevation myocardial infarction (STEMI) patients present with significant multivessel coronary artery disease, they are at high risk of subsequent adverse events. Whether complete revascularization guided by coronary angiography-derived fractional flow reserve (caFFR) further reduces such events risk is not fully investigated. METHODS In this study, 367 consecutive STEMI patients who underwent successful primary percutaneous coronary intervention (PCI) were enrolled. caFFR of all three coronary vessels were measured, including 367 culprit vessels and 703 non-culprit vessels. Complete revascularization was defined as post-PCI caFFR > 0.8 of all three coronary vessels. The primary endpoint was major adverse cardiovascular events (MACE, a composite of cardiovascular death, non-fatal recurrent myocardial infarction, ischemia-driven revascularization and non-fatal stroke/transient ischemic attacks) during follow-up. RESULTS At a median follow-up of 3.8 years, MACE had occurred in 39 patients of the 220 (17.7%) in the complete revascularization group as compared with 49 patients of the 131 (37.4%) in the incomplete revascularization group (hazard ratio [HR] 1.9; 95% confidence interval [CI] 1.2-3.0; p = 0.005). The incomplete revascularization in culprit vessels evaluated by caFFR showed the highest risk for MACE occurrence. CONCLUSIONS In STEMI patients with multivessel coronary artery disease, incomplete revascularization based on caFFR might contribute to identifying patients at high-risk.
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Affiliation(s)
- Jiahui Liu
- Department of Cardiology, Peking University First Hospital, Beijing, China
- Department of Hypertension, Peking University People's Hospital, Beijing, China
| | - Kaiping Zhang
- Department of Cardiology, Hospital 302 Attached to Guizhou Aviation Group, Guizhou, China
| | - Xingang Wang
- Department of Cardiology, Peking University First Hospital, Beijing, China
| | - Zhaoping Liu
- Department of Cardiology, Peking University First Hospital, Beijing, China
| | - Ming Chen
- Department of Cardiology, Peking University First Hospital, Beijing, China
| | - Fangfang Fan
- Department of Cardiology, Peking University First Hospital, Beijing, China
| | - Jia Jia
- Department of Cardiology, Peking University First Hospital, Beijing, China
- Institute of Cardiovascular Disease, Peking University First Hospital, Beijing, China
| | - Tao Hong
- Department of Cardiology, Peking University First Hospital, Beijing, China
| | - Jianping Li
- Department of Cardiology, Peking University First Hospital, Beijing, China
- Institute of Cardiovascular Disease, Peking University First Hospital, Beijing, China
| | - Yong Huo
- Department of Cardiology, Peking University First Hospital, Beijing, China
- Institute of Cardiovascular Disease, Peking University First Hospital, Beijing, China
| | - Yanjun Gong
- Department of Cardiology, Peking University First Hospital, Beijing, China
| | - Bo Zheng
- Department of Cardiology, Peking University First Hospital, Beijing, China.
- Institute of Cardiovascular Disease, Peking University First Hospital, Beijing, China.
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7
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Stone GW, Ali ZA, O'Brien SM, Rhodes G, Genereux P, Bangalore S, Mavromatis K, Horst J, Dressler O, Poh KK, Nath RK, Moorthy N, Witkowski A, Dwivedi SK, Bockeria O, Chen J, Smanio PEP, Picard MH, Chaitman BR, Berman DS, Shaw LJ, Boden WE, White HD, Fremes SE, Rosenberg Y, Reynolds HR, Spertus JA, Hochman JS, Maron DJ. Impact of Complete Revascularization in the ISCHEMIA Trial. J Am Coll Cardiol 2023; 82:1175-1188. [PMID: 37462593 PMCID: PMC10529674 DOI: 10.1016/j.jacc.2023.06.015] [Citation(s) in RCA: 13] [Impact Index Per Article: 13.0] [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: 02/24/2023] [Revised: 06/08/2023] [Accepted: 06/27/2023] [Indexed: 08/10/2023]
Abstract
BACKGROUND Anatomic complete revascularization (ACR) and functional complete revascularization (FCR) have been associated with reduced death and myocardial infarction (MI) in some prior studies. The impact of complete revascularization (CR) in patients undergoing an invasive (INV) compared with a conservative (CON) management strategy has not been reported. OBJECTIVES Among patients with chronic coronary disease without prior coronary artery bypass grafting randomized to INV vs CON management in the ISCHEMIA (International Study of Comparative Health Effectiveness with Medical and Invasive Approaches) trial, we examined the following: 1) the outcomes of ACR and FCR compared with incomplete revascularization; and 2) the potential impact of achieving CR in all INV patients compared with CON management. METHODS ACR and FCR in the INV group were assessed at an independent core laboratory. Multivariable-adjusted outcomes of CR were examined in INV patients. Inverse probability weighted modeling was then performed to estimate the treatment effect had CR been achieved in all INV patients compared with CON management. RESULTS ACR and FCR were achieved in 43.4% and 58.4% of 1,824 INV patients. ACR was associated with reduced 4-year rates of cardiovascular death or MI compared with incomplete revascularization. By inverse probability weighted modeling, ACR in all 2,296 INV patients compared with 2,498 CON patients was associated with a lower 4-year rate of cardiovascular death or MI (difference -3.5; 95% CI: -7.2% to 0.0%). In comparison, the event rate difference of cardiovascular death or MI for INV minus CON in the overall ISCHEMIA trial was -2.4%. Results were similar but less pronounced with FCR. CONCLUSIONS The outcomes of an INV strategy may be improved if CR (especially ACR) is achieved. (International Study of Comparative Health Effectiveness With Medical and Invasive Approaches [ISCHEMIA]; NCT01471522).
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Affiliation(s)
- Gregg W Stone
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA.
| | - Ziad A Ali
- St Francis Hospital, Roslyn, New York, USA; Cardiovascular Research Foundation, New York, New York, USA
| | - Sean M O'Brien
- Duke Clinical Research Institute, Durham, North Carolina, USA
| | - Grace Rhodes
- Duke Clinical Research Institute, Durham, North Carolina, USA
| | - Philippe Genereux
- Gagnon Cardiovascular Institute, Morristown Medical Center, Morristown, New Jersey, USA
| | | | | | - Jennifer Horst
- Cardiovascular Research Foundation, New York, New York, USA
| | | | - Kian Keong Poh
- National University Heart Center Singapore and the Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | | | - Nagaraja Moorthy
- Sri Jayadeva Institute of Cardiovascular Sciences and Research, Bangalore-Karnataka, Karnataka, India
| | | | | | - Olga Bockeria
- National Research Center for Cardiovascular Surgery, Moscow, Russia
| | - Jiyan Chen
- Guangdong Provincial People's Hospital, Guangdong, China
| | - Paola E P Smanio
- Instituto Dante Pazzanese de Cardiologia e Fleury Medicina e Saúde, São Paulo, Brazil
| | - Michael H Picard
- Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Bernard R Chaitman
- St Louis University School of Medicine Center for Comprehensive Cardiovascular Care, St Louis, Missouri, USA
| | | | - Leslee J Shaw
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - William E Boden
- Boston University School of Medicine, Boston, Massachusetts, USA
| | - Harvey D White
- Auckland City Hospital Green Lane Cardiovascular Services and University of Auckland, Auckland, New Zealand
| | - Stephen E Fremes
- University of Toronto, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Yves Rosenberg
- National Heart, Lung, and Blood Institute, Washington, DC, USA
| | | | - John A Spertus
- Saint Luke's Mid America Heart Institute and the University of Missouri, Kansas City, Kansas City, Missouri, USA
| | | | - David J Maron
- Department of Medicine, Stanford School of Medicine, Stanford, California, USA
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8
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Nakae M, Kainuma S, Toda K, Yoshikawa Y, Hata H, Yoshioka D, Kawamura T, Kawamura A, Kashiyama N, Ueno T, Kuratani T, Kondoh H, Hiraoka A, Sakaguchi T, Yoshitaka H, Shirakawa Y, Takahashi T, Sakaki M, Masai T, Komukai S, Kitamura T, Hirayama A, Shimomura Y, Miyagawa S. Impact of complete revascularization in coronary artery bypass grafting for ischemic cardiomyopathy. JTCVS Open 2023; 15:211-219. [PMID: 37808015 PMCID: PMC10556818 DOI: 10.1016/j.xjon.2023.04.008] [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] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/12/2021] [Revised: 03/24/2023] [Accepted: 04/06/2023] [Indexed: 10/10/2023]
Abstract
Objective In patients with ischemic cardiomyopathy, coronary artery bypass grafting ensures better survival than medical therapy. However, the long-term clinical impact of complete revascularization remains unclear. This observational study aimed to evaluate the effects of complete revascularization on long-term survival and left ventricular functional recovery in patients with ischemic cardiomyopathy undergoing coronary artery bypass grafting. Methods We retrospectively reviewed outcomes of 498 patients with ischemic cardiomyopathy who underwent complete (n = 386) or incomplete (n = 112) myocardial revascularization between 1993 and 2015. The baseline characteristics were adjusted using inverse probability of treatment weighting to reduce the impact of treatment bias and potential confounding. The mean follow-up duration was 77.2 ± 42.8 months in survivors. Results The overall 5-year survival rate (complete revascularization, 72.5% vs incomplete revascularization, 57.9%, P = .03) and freedom from all-cause death and/or readmission due to heart failure (54.5% vs 40.1%, P = .007) were significantly greater in patients with complete revascularization than those with incomplete revascularization. After adjustments using inverse probability of treatment weighting, the complete revascularization group demonstrated a lower risk of all-cause death (hazard ratio, 0.61; 95% confidence interval, 0.43-0.86; P = .005) and composite adverse events (hazard ratio, 0.59; 95% confidence interval, 0.44-0.79; P < .001) and a greater improvement in the left ventricular ejection fraction 1-year postoperatively (absolute change: 11.0 ± 11.9% vs 8.3 ± 11.4%, interaction effect P = .05) than the incomplete revascularization group. Conclusions In patients with ischemic cardiomyopathy undergoing coronary artery bypass grafting, complete revascularization was associated with better long-term outcomes and greater left ventricular functional recovery and should be encouraged whenever possible.
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Affiliation(s)
- Masaro Nakae
- Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Satoshi Kainuma
- Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Koichi Toda
- Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Yasushi Yoshikawa
- Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Hiroki Hata
- Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Daisuke Yoshioka
- Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Takuji Kawamura
- Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Ai Kawamura
- Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Noriyuki Kashiyama
- Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Takayoshi Ueno
- Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Toru Kuratani
- Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Haruhiko Kondoh
- Japan Organization of Occupational Health and Safety Osaka Rosai Hospital, Sakai, Osaka, Japan
| | - Arudo Hiraoka
- Sakakibara Heart Institute of Okayama, Okayama, Japan
| | | | | | | | | | - Masayuki Sakaki
- National Hospital Organization Osaka National Hospital, Osaka, Osaka, Japan
| | | | - Sho Komukai
- Division of Biomedical Statistics, Department of Integrated Medicine, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Tetsuhisa Kitamura
- Division of Environmental Medicine and Population Sciences, Department of Social and Environmental Medicine, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Atsushi Hirayama
- Public Health, Department of Social and Environmental Medicine, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Yoshimitsu Shimomura
- Division of Environmental Medicine and Population Sciences, Department of Social and Environmental Medicine, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Shigeru Miyagawa
- Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Osaka Cardiovascular Surgery Research (OSCAR) Group
- Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
- Japan Organization of Occupational Health and Safety Osaka Rosai Hospital, Sakai, Osaka, Japan
- Sakakibara Heart Institute of Okayama, Okayama, Japan
- Osaka Police Hospital, Osaka, Osaka, Japan
- National Hospital Organization Osaka National Hospital, Osaka, Osaka, Japan
- Sakurabashi Watanabe Hospital, Osaka, Osaka, Japan
- Division of Biomedical Statistics, Department of Integrated Medicine, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
- Division of Environmental Medicine and Population Sciences, Department of Social and Environmental Medicine, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
- Public Health, Department of Social and Environmental Medicine, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
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9
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Bruno F, Marengo G, De Filippo O, Wanha W, Leonardi S, Raposeiras Roubin S, Fabris E, Popovic M, Giannino G, Truffa A, Huczek Z, Gaibazzi N, Ielasi A, Cortese B, Borin A, Núñez‐Gil IJ, Melis D, Ugo F, Bianco M, Barbieri L, Marchini F, Desperak P, Montalto C, Melendo‐Viu M, Elia E, Mancone M, Buono A, Ferrandez‐Escarabajal M, Morici N, Scaglione M, Tuttolomondo D, Sardella G, Gasior M, Mazurek M, Gallone G, Pagliaro B, Lopiano C, Campo G, Wojakowski W, Abu‐Assi E, Sinagra G, De Ferrari GM, D'Ascenzo F. Impact of Complete Revascularization on Development of Heart Failure in Patients With Acute Coronary Syndrome and Multivessel Disease: A Subanalysis of the CORALYS Registry. J Am Heart Assoc 2023; 12:e028475. [PMID: 37489724 PMCID: PMC10492970 DOI: 10.1161/jaha.122.028475] [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: 04/04/2023] [Accepted: 06/02/2023] [Indexed: 07/26/2023]
Abstract
Background The impact of complete revascularization (CR) on the development of heart failure (HF) in patients with acute coronary syndrome and multivessel coronary artery disease undergoing percutaneous coronary intervention remains to be elucidated. Methods and Results Consecutive patients with acute coronary syndrome with multivessel coronary artery disease from the CORALYS (Incidence and Predictors of Heart Failure After Acute Coronary Syndrome) registry were included. Incidence of first hospitalization for HF or cardiovascular death was the primary end point. Patients were stratified according to completeness of coronary revascularization. Of 14 699 patients in the CORALYS registry, 5054 presented with multivessel disease. One thousand four hundred seventy-three (29.2%) underwent CR, while 3581 (70.8%) did not. Over 5 years follow-up, CR was associated with a reduced incidence of the primary end point (adjusted hazard ratio [HR], 0.66 [95% CI, 0.51-0.85]), first HF hospitalization (adjusted HR, 0.67 [95% CI, 0.49-0.90]) along with all-cause death and cardiovascular death alone (adjusted HR, 0.74 [95% CI, 0.56-0.97] and HR, 0.56 [95% CI, 0.38-0.84], respectively). The results were consistent in the propensity-score matching population and in inverse probability treatment weighting analysis. The benefit of CR was consistent across acute coronary syndrome presentations (HR, 0.59 [95% CI, 0.39-0.89] for ST-segment elevation myocardial infarction and HR, 0.71 [95% CI, 0.50-0.99] for non-ST-elevation acute coronary syndrome) and in patients with left ventricular ejection fraction >40% (HR, 0.52 [95% CI, 0.37-0.72]), while no benefit was observed in patients with left ventricular ejection fraction ≤40% (HR, 0.77 [95% CI, 0.37-1.10], P for interaction 0.04). Conclusions CR after acute coronary syndrome reduced the risk of first hospitalization for HF and cardiovascular death, as well as first HF hospitalization, and cardiovascular and overall death both in patients with ST-segment elevation myocardial infarction and non-ST-elevation acute coronary syndrome. Registration URL: https://www.clinicaltrials.gov; Unique identifier: NCT04895176.
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Affiliation(s)
- Francesco Bruno
- Division of Cardiology, “Città della Salute e della Scienza di Torino” Hospital, Department of Medical SciencesUniversity of TurinItaly
| | - Giorgio Marengo
- Division of Cardiology, “Città della Salute e della Scienza di Torino” Hospital, Department of Medical SciencesUniversity of TurinItaly
| | - Ovidio De Filippo
- Division of Cardiology, “Città della Salute e della Scienza di Torino” Hospital, Department of Medical SciencesUniversity of TurinItaly
| | - Wojciech Wanha
- Department of Cardiology and Structural Heart DiseasesMedical University of SilesiaKatowicePoland
| | - Sergio Leonardi
- Fondazione IRCCS Policlinico San MatteoCoronary Care UnitPaviaItaly
| | | | - Enrico Fabris
- Cardiovascular Department, Azienda Sanitaria Universitaria Giuliano IsontinaUniversity of TriesteItaly
| | - Maja Popovic
- Department of Medical SciencesUniversity of TurinItaly
| | - Giuseppe Giannino
- Division of Cardiology, “Città della Salute e della Scienza di Torino” Hospital, Department of Medical SciencesUniversity of TurinItaly
| | | | - Zenon Huczek
- 1st Department of CardiologyMedical University of WarsawWarszawaPoland
| | | | - Alfonso Ielasi
- U.O. di Cardiologia Clinica ed InterventisticaIstituto Clinico Sant’AmbrogioMilanItaly
| | - Bernardo Cortese
- Cardiovascular Research TeamSan Carlo ClinicMilanItaly
- Fondazione Ricerca e Innovazione CardiovascolareMilanItaly
| | - Andrea Borin
- Division of Cardiology, “Città della Salute e della Scienza di Torino” Hospital, Department of Medical SciencesUniversity of TurinItaly
| | | | - Daniele Melis
- Division of Cardiology, “Città della Salute e della Scienza di Torino” Hospital, Department of Medical SciencesUniversity of TurinItaly
| | - Fabrizio Ugo
- Department of CardiologySant’Andrea HospitalVercelliItaly
| | - Matteo Bianco
- Division of CardiologySan Luigi Gonzaga University Hospital, OrbassanoTurinItaly
| | - Lucia Barbieri
- Division of CardiologyFondazione IRCCS Ca’ Granda Ospedale Maggiore PoliclinicoMilanItaly
- University of MilanMilanItaly
| | - Federico Marchini
- Cardiovascular Institute, Azienda Ospedaliero Universitaria di FerraraConaItaly
| | - Piotr Desperak
- Department of Cardiology and Structural Heart DiseasesMedical University of SilesiaKatowicePoland
| | - Claudio Montalto
- Fondazione IRCCS Policlinico San MatteoCoronary Care UnitPaviaItaly
| | | | - Edoardo Elia
- Division of Cardiology, “Città della Salute e della Scienza di Torino” Hospital, Department of Medical SciencesUniversity of TurinItaly
| | - Massimo Mancone
- Dipartimento di Scienze Cliniche Internistiche, Anestesiologiche e CardiovascolariSapienza Università di RomaRomaItaly
| | - Andrea Buono
- Interventional Cardiology Unit, Cardiovascular DepartmentFondazione Poliambulanza Istituto OspedalieroBresciaItaly
| | | | - Nuccia Morici
- IRCCS S. Maria Nascente‐Fondazione Don Carlo Gnocchi ONLUSMilanItaly
| | | | | | - Gennaro Sardella
- Dipartimento di Scienze Cliniche Internistiche, Anestesiologiche e CardiovascolariSapienza Università di RomaRomaItaly
| | - Mariusz Gasior
- Department of Cardiology and Structural Heart DiseasesMedical University of SilesiaKatowicePoland
| | - Maciej Mazurek
- 1st Department of CardiologyMedical University of WarsawWarszawaPoland
| | - Guglielmo Gallone
- Division of Cardiology, “Città della Salute e della Scienza di Torino” Hospital, Department of Medical SciencesUniversity of TurinItaly
| | - Beniamino Pagliaro
- Cardiovascular Institute, Azienda Ospedaliero Universitaria di FerraraConaItaly
- IRCCS Humanitas Research HospitalRozzano‐MilanItaly
| | - Clara Lopiano
- Cardiovascular Institute, Azienda Ospedaliero Universitaria di FerraraConaItaly
- IRCCS Humanitas Research HospitalRozzano‐MilanItaly
| | - Gianluca Campo
- Cardiovascular Institute, Azienda Ospedaliero Universitaria di FerraraConaItaly
| | - Wojciech Wojakowski
- Department of Cardiology and Structural Heart DiseasesMedical University of SilesiaKatowicePoland
| | | | - Gianfranco Sinagra
- Cardiovascular Department, Azienda Sanitaria Universitaria Giuliano IsontinaUniversity of TriesteItaly
| | - Gaetano Maria De Ferrari
- Division of Cardiology, “Città della Salute e della Scienza di Torino” Hospital, Department of Medical SciencesUniversity of TurinItaly
| | - Fabrizio D'Ascenzo
- Division of Cardiology, “Città della Salute e della Scienza di Torino” Hospital, Department of Medical SciencesUniversity of TurinItaly
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10
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Ahmad Y, Velazquez EJ. The Interplay of Complete Revascularization and Angina: More Is More? J Am Coll Cardiol 2023; 82:314-316. [PMID: 37468186 DOI: 10.1016/j.jacc.2023.06.002] [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: 05/30/2023] [Accepted: 06/07/2023] [Indexed: 07/21/2023]
Affiliation(s)
- Yousif Ahmad
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, Connecticut, USA.
| | - Eric J Velazquez
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, Connecticut, USA
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11
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Mavromatis K, Jones PG, Ali ZA, Stone GW, Rhodes GM, Bangalore S, O'Brien S, Genereux P, Horst J, Dressler O, Goodman S, Alexander K, Mathew A, Chen J, Bhargava B, Uxa A, Boden WE, Mark DB, Reynolds HR, Maron DJ, Hochman JS, Spertus JA. Complete Revascularization and Angina-Related Health Status in the ISCHEMIA Trial. J Am Coll Cardiol 2023; 82:295-313. [PMID: 37468185 PMCID: PMC10551823 DOI: 10.1016/j.jacc.2023.05.025] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [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: 02/22/2023] [Accepted: 05/08/2023] [Indexed: 07/21/2023]
Abstract
BACKGROUND The impact of complete revascularization (CR) on angina-related health status (symptoms, function, quality of life) in chronic coronary disease (CCD) has not been well studied. OBJECTIVES Among patients with CCD randomized to invasive (INV) vs conservative (CON) management in ISCHEMIA (International Study of Comparative Health Effectiveness with Medical and Invasive Approaches), we compared the following: 1) the impact of anatomic and functional CR on health status compared with incomplete revascularization (ICR); and 2) the predicted impact of achieving CR in all INV patients compared with CON. METHODS Multivariable regression adjusting for patient characteristics was used to compare 12-month health status after independent core laboratory-defined CR vs ICR in INV patients who underwent revascularization. Propensity-weighted modeling was then performed to estimate the treatment effect had CR or ICR been achieved in all INV patients, compared with CON. RESULTS Anatomic and functional CR were achieved in 43.3% and 57.8% of 1,641 INV patients, respectively. Among revascularized patients, CR was associated with improved Seattle Angina Questionnaire Angina Frequency compared with ICR after adjustment for baseline differences. After modeling CR and ICR in all INV patients, patients with CR and ICR each had greater improvements in health status than CON, with better health status with CR than ICR. The projected benefits of CR were most pronounced in patients with baseline daily/weekly angina and not seen in those with no angina. CONCLUSIONS Among patients with CCD in ISCHEMIA, health status improved more with CR compared with ICR or CON, particularly in those with frequent angina. Anatomic and functional CR provided comparable improvements in quality of life. (International Study of Comparative Health Effectiveness With Medical and Invasive Approaches [ISCHEMIA]; NCT01471522).
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Affiliation(s)
- Kreton Mavromatis
- Emory University, Atlanta VA Healthcare System, Atlanta, Georgia, USA.
| | - Philip G Jones
- Saint Luke's Mid America Heart Institute/University of Missouri - Kansas City (UMKC), Kansas City, Missouri, USA
| | - Ziad A Ali
- St Francis Hospital and Heart Center, Roslyn, New York, USA; Cardiovascular Research Foundation, New York, New York, USA
| | - Gregg W Stone
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Grace M Rhodes
- Duke Clinical Research Institute, Durham, North Carolina, USA
| | | | - Sean O'Brien
- Duke Clinical Research Institute, Durham, North Carolina, USA
| | - Philippe Genereux
- Gagnon Cardiovascular Institute, Morristown Medical Center, Morristown, New Jersey, USA
| | - Jennifer Horst
- Cardiovascular Research Foundation, New York, New York, USA
| | | | - Shaun Goodman
- St Michael's Hospital, University of Toronto, and the Canadian Heart Research Centre, Toronto, Ontario, Canada
| | - Karen Alexander
- Duke Clinical Research Institute, Durham, North Carolina, USA
| | - Anoop Mathew
- University of Alberta Hospital, Edmonton, Alberta, Canada
| | - Jiyan Chen
- Guangdong Provincial People's Hospital, Guangdong, China
| | | | - Amar Uxa
- University of Toronto and University Health Network/Mount Sinai Hospital, Toronto, Ontario, Canada
| | - William E Boden
- VA New England Healthcare System, Bedford, Massachusetts, USA
| | - Daniel B Mark
- Duke Clinical Research Institute, Durham, North Carolina, USA
| | | | - David J Maron
- Department of Medicine, Stanford University, Stanford, California, USA
| | | | - John A Spertus
- Saint Luke's Mid America Heart Institute/University of Missouri - Kansas City (UMKC), Kansas City, Missouri, USA
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12
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Bustea C, Tit DM, Bungau AF, Bungau SG, Pantea VA, Babes EE, Pantea-Roșan LR. Predictors of Readmission after the First Acute Coronary Syndrome and the Risk of Recurrent Cardiovascular Events-Seven Years of Patient Follow-Up. Life (Basel) 2023; 13:life13040950. [PMID: 37109479 PMCID: PMC10140970 DOI: 10.3390/life13040950] [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] [Subscribe] [Scholar Register] [Received: 03/05/2023] [Revised: 03/24/2023] [Accepted: 04/03/2023] [Indexed: 04/29/2023] Open
Abstract
Recurrent hospitalization after acute coronary syndromes (ACS) is common. Identifying risk factors associated with subsequent cardiovascular events and hospitalization is essential for the management of these patients. Our research consisted in observing the outcomes of subjects after they suffered an acute coronary event and identifying the factors that can predict rehospitalization in the first 12 months and the recurrence of another acute coronary episode. Data from 362 patients admitted with ACS during 2013 were studied. Recurrent hospitalizations were retrospectively reviewed from medical charts and electronic hospital archives over a period of seven years. The mean age of the studied population was 64.57 ± 11.79 years, 64.36% of them being males. The diagnosis of ACS without ST elevation was registered in 53.87% of the patients at index hospitalization. More than half had recurrent hospitalization in the first year after the first ACS episode. Patients with lower ejection fraction (39.20 ± 6.85 vs. 42.24 ± 6.26, p < 0.001), acute pulmonary edema during the first hospitalization (6.47% vs. 1.24%, p = 0.022), coexistent valvular heart disease (69.15% vs. 55.90%, p = 0.017), and three-vessel disease (18.90% vs. 7.45%, p = 0.002) were more frequently readmitted in the following twelve months after their first acute coronary event, while those with complete revascularization were less frequently admitted (24.87% vs. 34.78%, p = 0.005). In multiple regression, complete revascularization during the index event (HR = 0.58, 95% CI 0.35-0.95, p = 0.03) and a higher LVEF (left ventricular ejection fraction) (HR = 0.95, 95% CI 0.92-0.988, p = 0.009) remained independent predictors of fewer early readmissions. Complete revascularization of the coronary lesions at the time of the first event and a preserved LVEF were found to be the predictors of reduced hospitalizations in the first year after an acute coronary event.
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Affiliation(s)
- Cristiana Bustea
- Department of Preclinical Disciplines, Faculty of Medicine and Pharmacy, University of Oradea, 410073 Oradea, Romania
| | - Delia Mirela Tit
- Department of Pharmacy, Faculty of Medicine and Pharmacy, University of Oradea, 410028 Oradea, Romania
- Doctoral School of Biomedical Sciences, University of Oradea, 410087 Oradea, Romania
| | - Alexa Florina Bungau
- Department of Preclinical Disciplines, Faculty of Medicine and Pharmacy, University of Oradea, 410073 Oradea, Romania
- Doctoral School of Biomedical Sciences, University of Oradea, 410087 Oradea, Romania
| | - Simona Gabriela Bungau
- Department of Pharmacy, Faculty of Medicine and Pharmacy, University of Oradea, 410028 Oradea, Romania
- Doctoral School of Biomedical Sciences, University of Oradea, 410087 Oradea, Romania
| | - Vlad Alin Pantea
- Department of Dental Medicine, Faculty of Medicine and Pharmacy, University of Oradea, 410073 Oradea, Romania
| | - Elena Emilia Babes
- Department of Medical Disciplines, Faculty of Medicine and Pharmacy, University of Oradea, 410073 Oradea, Romania
| | - Larisa Renata Pantea-Roșan
- Department of Medical Disciplines, Faculty of Medicine and Pharmacy, University of Oradea, 410073 Oradea, Romania
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13
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Spacek M, Vacha J, Precek J, Hutyra M, Nykl R, Sluka M, Taborsky M. Complete revascularization of multivessel coronary artery disease in patients with ST elevation acute coronary syndrome - for whom and when? A comprehensive review. Biomed Pap Med Fac Univ Palacky Olomouc Czech Repub 2023; 167:16-23. [PMID: 35703363 DOI: 10.5507/bp.2022.024] [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] [Subscribe] [Scholar Register] [Received: 03/25/2022] [Accepted: 05/17/2022] [Indexed: 11/23/2022] Open
Abstract
Atherosclerosis is the most common cause of coronary steno-occlusive disease and acute myocardial infarction is the leading cause of death in industrialized countries. In patients with acute ST elevation myocardial infarction (STEMI), there is unquestionable evidence that primary percutaneous coronary intervention providing recanalization of the infarct related artery (IRA) is the preferred reperfusion strategy. Nevertheless, up to 50% of patients with STEMI have multivessel coronary artery disease defined as at least 50% stenosis exclusive of IRA. There is conflicting data regarding the optimal treatment strategy and timing in such patients. Currently, it is assumed that stable patients might benefit from complete revascularization particularly in reducing the need for future unplanned procedures but only culprit lesion should be treated during index procedure in unstable patients. In this article, we provide a comprehensive overview of this important and currently highly debated topic.
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Affiliation(s)
- Miloslav Spacek
- Department of Internal Medicine I - Cardiology, Faculty of Medicine and Dentistry, Palacky University Olomouc and University Hospital Olomouc, Olomouc, Czech Republic
| | - Jan Vacha
- Department of Internal Medicine I - Cardiology, Faculty of Medicine and Dentistry, Palacky University Olomouc and University Hospital Olomouc, Olomouc, Czech Republic
| | - Jan Precek
- Department of Internal Medicine I - Cardiology, Faculty of Medicine and Dentistry, Palacky University Olomouc and University Hospital Olomouc, Olomouc, Czech Republic
| | - Martin Hutyra
- Department of Internal Medicine I - Cardiology, Faculty of Medicine and Dentistry, Palacky University Olomouc and University Hospital Olomouc, Olomouc, Czech Republic
| | - Radomir Nykl
- Department of Internal Medicine I - Cardiology, Faculty of Medicine and Dentistry, Palacky University Olomouc and University Hospital Olomouc, Olomouc, Czech Republic
| | - Martin Sluka
- Department of Internal Medicine I - Cardiology, Faculty of Medicine and Dentistry, Palacky University Olomouc and University Hospital Olomouc, Olomouc, Czech Republic
| | - Milos Taborsky
- Department of Internal Medicine I - Cardiology, Faculty of Medicine and Dentistry, Palacky University Olomouc and University Hospital Olomouc, Olomouc, Czech Republic
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14
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Mavromatis K, Sandesara PB. Complete Revascularization in Left Main Disease: Is it Important? JACC Asia 2023; 3:75-77. [PMID: 36873759 PMCID: PMC9982217 DOI: 10.1016/j.jacasi.2022.11.006] [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] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Affiliation(s)
- Kreton Mavromatis
- Atlanta VA Healthcare System, Decatur, Georgia, USA.,Division of Cardiology, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Pratik B Sandesara
- Division of Cardiology, Emory University School of Medicine, Atlanta, Georgia, USA
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Almeida I, Chin J, Santos H, Santos M, Miranda H, Almeida S, Sousa C, Almeida L. Revascularization strategies in STEMI and multivessel disease. Acta Cardiol 2023; 78:32-39. [PMID: 34875967 DOI: 10.1080/00015385.2021.1999570] [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] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
INTRODUCTION The main treatment for ST-elevation myocardial infarction (STEMI) is the re-establishment of the coronary flow of infarct-related arteries. However, 50% of cases present multivessel disease (MVD), negatively affecting mortality. Complete revascularization (CR) is currently advocated since it reduces major adverse cardiovascular events (MACE). OBJECTIVE Evaluation of the adopted revascularization strategy and its prognostic value in a Portuguese cohort of STEMI patients with MVD. MATERIAL AND METHODS Retrospective analysis of patients admitted with STEMI included in the Portuguese Registry of Acute Coronary Syndromes between 2010 and 2019. Patients were divided in two groups regarding revascularization strategy (complete versus incomplete) and compared. Independent predictors of a composite of all-cause mortality and rehospitalization for cardiovascular causes were assessed by multivariate logistic regression. RESULTS A total of 3500 patients were included. A CR strategy was performed in 21.8% of patients, who were younger and healthier. They also presented more hemodynamically stable and had less kidney dysfunction and anaemia. Their coronary anatomy was less complex, with a higher prevalence of 2-vessel and a lower proportion of chronic occlusions. In-hospital and 1-year adverse events were less frequent between patients with CR. CONCLUSION In hemodynamically stable STEMI patients, CR substantially reduced in-hospital and 1-year all-cause mortality and MACE.
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Affiliation(s)
- Inês Almeida
- Cardiology Departement, Barreiro-Montijo Hospital Center, Portugal
| | - Joana Chin
- Cardiology Departement, Barreiro-Montijo Hospital Center, Portugal
| | - Hélder Santos
- Cardiology Departement, Barreiro-Montijo Hospital Center, Portugal
| | - Mariana Santos
- Cardiology Departement, Barreiro-Montijo Hospital Center, Portugal
| | - Hugo Miranda
- Cardiology Departement, Barreiro-Montijo Hospital Center, Portugal
| | - Samuel Almeida
- Cardiology Departement, Barreiro-Montijo Hospital Center, Portugal
| | - Catarina Sousa
- Cardiology Departement, Barreiro-Montijo Hospital Center, Portugal.,Faculty of Medicine, University of Lisbon, Cardiovascular Center of University of Lisbon, Portugal
| | - Lurdes Almeida
- Cardiology Departement, Barreiro-Montijo Hospital Center, Portugal
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Vasiljevs D, Kakurina N, Pontaga N, Kokina B, Osipovs V, Sorokins N, Pikta S, Trusinskis K, Lejnieks A. Culprit versus Complete Revascularization during the Initial Intervention in Patients with Acute Coronary Syndrome Using a Virtual Treatment Planning Tool: Results of a Single-Center Pilot Study. Medicina (Kaunas) 2023; 59:medicina59020270. [PMID: 36837471 PMCID: PMC9967361 DOI: 10.3390/medicina59020270] [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] [Figures] [Subscribe] [Scholar Register] [Received: 12/26/2022] [Revised: 01/12/2023] [Accepted: 01/27/2023] [Indexed: 02/01/2023]
Abstract
Background and Objectives: The revascularization strategy for percutaneous coronary intervention (PCI) in patients with multivessel (MV) acute coronary syndrome (ACS) remains controversial. Certain gaps in the evidence are related to the optimal timing of non-culprit lesion revascularization and the utility of instantaneous wave-free ratio (iFR) in the management of MV ACS intervention. The major benefits of iFR utilization in MV ACS patients in one-stage complete revascularization are: (1) the possibility to virtually plan the PCI, both the location and the extension of the necessary stenting to achieve the prespecified final hemodynamic result; (2) the opportunity to validate the final hemodynamic result of the PCI, both in culprit artery and all non-culprit arteries and (3) the value of obliviating the uncomfortable, costly, time consuming and sometimes deleterious effects from Adenosine, as there is no requirement for administration. Thus, iFR use fosters the achievement of physiologically appropriate complete revascularization in MV ACS patients during acute hospitalization. Materials and Methods: This pilot study was aimed to test the feasibility of a randomized trial research protocol as well as to assess patient safety signals of co-registration iFR-guided one-stage complete revascularization compared with that of standard staged angiography-guided PCI in de novo patients with MV ACS. This was a single-center, prospective, randomized, open-label clinical trial consecutively screening patients with ACS for MV disease. The intervention strategy of interest was iFR-guided physiologically complete one-stage revascularization, in which the virtual PCI planning of non-culprit lesions and the intervention itself were performed in one stage directly following treatment of the culprit lesion and other critical stenosis of more than ninety percent. Seventeen patients were recruited and completed the 3-month follow-up. Results: Index PCI duration was significantly longer while the volume of contrast media delivered in index PCI was significantly greater in the iFR-guided group than in the angiography-guided group (119.4 ± 40.7 vs. 47 ± 15.5 min, p = 0.004; and 360 ± 97.9 vs. 192.5 ± 52.8 mL, p = 0.003). There were no significant differences in PCI-related major adverse cardiovascular events (MACE) between the groups during acute hospitalization and at 3-months follow-up. One-stage iFR-guided PCI requires fewer PCI attempts until complete revascularization than does angiography-guided staged PCI. Conclusions: Complete revascularization with the routine use of the virtual planning tool in one-stage iFR-guided PCI is a feasible practical strategy in an everyday Cath lab environment following the protocol designed for the study. No statistically significant safety signals were documented in the number of PCI related MACE during the 3-month follow-up.
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Affiliation(s)
- Deniss Vasiljevs
- Daugavpils Regional Hospital, 20 Vasarnicu Str., LV-5417 Daugavpils, Latvia
- Department of Internal Diseases, Riga Stradins University, 16 Dzirciema Str., LV-1007 Riga, Latvia
- Correspondence: ; Tel.: +371-6544-0858
| | - Natalja Kakurina
- Daugavpils Regional Hospital, 20 Vasarnicu Str., LV-5417 Daugavpils, Latvia
| | - Natalja Pontaga
- Daugavpils Regional Hospital, 20 Vasarnicu Str., LV-5417 Daugavpils, Latvia
| | - Baiba Kokina
- Department of Internal Diseases, Riga Stradins University, 16 Dzirciema Str., LV-1007 Riga, Latvia
| | - Vladimirs Osipovs
- Daugavpils Regional Hospital, 20 Vasarnicu Str., LV-5417 Daugavpils, Latvia
| | - Nikolajs Sorokins
- Daugavpils Regional Hospital, 20 Vasarnicu Str., LV-5417 Daugavpils, Latvia
| | - Sergejs Pikta
- Daugavpils Regional Hospital, 20 Vasarnicu Str., LV-5417 Daugavpils, Latvia
| | - Karlis Trusinskis
- Department of Internal Diseases, Riga Stradins University, 16 Dzirciema Str., LV-1007 Riga, Latvia
- Latvian Center of Cardiology, Pauls Stradins Clinical University Hospital, 13 Pilsonu Str., LV-1002 Riga, Latvia
| | - Aivars Lejnieks
- Department of Internal Diseases, Riga Stradins University, 16 Dzirciema Str., LV-1007 Riga, Latvia
- Riga East Clinical University Hospital, 2 Hipokrata Str., LV-1038 Riga, Latvia
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Henry TD, Kereiakes DJ. QFR Facilitated Functional Lesion Assessment to Guide Revascularization: The Next Paradigm Shift? JACC Cardiovasc Interv 2022; 15:2503-2505. [PMID: 36543444 DOI: 10.1016/j.jcin.2022.10.061] [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: 10/26/2022] [Accepted: 10/31/2022] [Indexed: 12/24/2022]
Affiliation(s)
- Timothy D Henry
- Carl and Edyth Lindner Center for Research and Education, the Christ Hospital, Cincinnati, Ohio, USA; Christ Hospital Heart and Vascular Institute, the Christ Hospital, Cincinnati, Ohio, USA.
| | - Dean J Kereiakes
- Carl and Edyth Lindner Center for Research and Education, the Christ Hospital, Cincinnati, Ohio, USA; Christ Hospital Heart and Vascular Institute, the Christ Hospital, Cincinnati, Ohio, USA
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Hu MJ, Li XS, Yang YJ. Impact of percutaneous coronary intervention on chronic total occlusion in the non-infarct-related artery in patients with STEMI: a systematic review and meta-analysis. SCAND CARDIOVASC J 2022; 56:157-165. [PMID: 35674511 DOI: 10.1080/14017431.2022.2085319] [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] [Indexed: 10/18/2022]
Abstract
OBJECTIVES We sought to compare the clinical outcomes between culprit-only percutaneous coronary intervention (PCI) versus multivessel PCI (MV-PCI) in patients with ST-segment elevation myocardial infarction (STEMI) accompanied by chronic total occlusion (CTO) in the non-infarct-related artery(non-IRA). DESIGN Studies that compared culprit-only PCI versus MV-PCI in patients with STEMI accompanied by CTO in the non-IRA were included. Random odds ratio (OR) and 95% confidence interval (CI) were calculated. RESULTS Eight studies with 2,259 patients were included. The results suggested that in patients with STEMI accompanied by CTO in the non-IRA, culprit-only PCI was associated with higher risks of all-cause mortality (OR: 2.89; 95% CI: 2.09-4.00; I2 = 0.0%), cardiac death (OR: 3.12; 95% CI: 2.05-4.75; I2 = 16.8%), stroke (OR: 2.80; 95% CI: 1.04-7.53; I2 = 0.0%), major adverse cardiovascular event (MACE; OR: 2.06; 95% CI: 1.39-3.06; I2 = 54.0%), and heart failure (OR: 1.99; 95% CI: 1.22-3.24; I2 = 0.0%) compared with staged MV-PCI, which were mainly derived from retrospective studies. No differences were observed in myocardial infarction or revascularization. Pooled multivariable adjusted results consistently indicated that staged MV-PCI was superior to culprit-only PCI. CONCLUSIONS For patients with STEMI accompanied by CTO in the non-IRA, staged MV-PCI may be better compared with culprit-only PCI due to potential reduced risks of all-cause mortality, cardiac death, stroke, MACE, and heart failure. Meanwhile, further randomized trials are warranted to confirm or refute our findings.
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Affiliation(s)
- Meng-Jin Hu
- State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Xiao-Song Li
- State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Yue-Jin Yang
- State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
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Kim MC, Lim Y, Ahn Y, Ahn JH, Lee SH, Hyun DY, Cho KH, Sim DS, Hong YJ, Kim JH, Jeong MH. Incidence, Predictive Factors and Long-Term Clinical Impact of Left Ventricular Remodeling According to the Completeness of Revascularization in Patients with ST-Elevation Myocardial Infarction and Multivessel Disease. J Clin Med 2022; 11. [PMID: 36362481 DOI: 10.3390/jcm11216252] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2022] [Revised: 10/12/2022] [Accepted: 10/18/2022] [Indexed: 11/24/2022] Open
Abstract
In this study, we identified several factors related to left ventricular remodeling (LVR) and examined the impact of LVR on the prognosis of patients with ST-elevated myocardial infarction and multivessel disease treated with complete (CR) or incomplete (IR) revascularization. LVR was defined as an LV end-diastolic diameter >55 mm. A total of 262 patients without LVR at presentation were followed up with echocardiography between 1 month and 1 year. The primary outcome was a composite of all-cause death (AD), MI, and heart failure (HF), referred to as a major adverse cardiovascular endpoint (MACE). Then, each variable was analyzed as a secondary outcome. Follow-up echocardiography identified 26 patients (9.9%) with LVR. LVR was associated with an initial LV ejection fraction <50%, Killip 3 disease at presentation, and a peak troponin I level >70 mg/dL. Survival analysis showed an association between LVR and adverse outcomes only in the IR group, in which the adjusted hazard ratio (HR) was increased for the MACE (HR = 3.22, 95% confidence interval (CI) = 1.19−8.71, p = 0.002) and HF (HR = 21.37, 95% CI = 4.47−102.09, p< 0.001), but not for the CR group. In STEMI with MVD, LVR within the first year after percutaneous coronary intervention was associated with worse outcomes in the IR but not the CR group.
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20
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Kajana V, Baldi E, Gentile FR, Compagnoni S, Quilico F, Vicini Scajola L, Repetto A, Mandurino-Mirizzi A, Ferlini M, Marinoni B, Ferrario Ormezzano M, Primi R, Bendotti S, Currao A, Savastano S. Complete Revascularization and One-Year Survival with Good Neurological Outcome in Patients Resuscitated from an Out-of-Hospital Cardiac Arrest. J Clin Med 2022; 11:jcm11175071. [PMID: 36079003 PMCID: PMC9456720 DOI: 10.3390/jcm11175071] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2022] [Revised: 08/22/2022] [Accepted: 08/26/2022] [Indexed: 11/16/2022] Open
Abstract
Background. The survival benefit of complete versus infarct-related artery (IRA)-only revascularization during the index hospitalization in patients resuscitated from an out-of-hospital cardiac arrest (OHCA) with multivessel disease is unknown. Methods. We considered all the OHCA patients prospectively enrolled in the Lombardia Cardiac Arrest Registry (Lombardia CARe) from 1 January 2015 to 1 May 2021 who underwent coronary angiography (CAG) at the Fondazione IRCCS Policlinico San Matteo (Pavia). Patients’ prehospital, angiographical and survival data were reviewed. Results. Out of 239 patients, 119 had a multivessel coronary disease: 69% received IRA-only revascularization, and 31% received a complete revascularization: 8 during the first procedure and 29 in a staged-procedure after a median time of 5 days [IQR 2.5−10.3]. The complete revascularization group showed significantly higher one-year survival with good neurological outcome than the IRA-only group (83.3% vs. 30.4%, p < 0.001). After correcting for cardiac arrest duration, shockable presenting rhythm, peak of Troponin-I, creatinine on admission and the need for circulatory support, complete revascularization was independently associated with the probability of death and poor neurological outcome [HR 0.3 (95%CI 0.1−0.8), p = 0.02]. Conclusions. This observation study shows that complete myocardial revascularization during the index hospitalization improves one-year survival with good neurological outcome in patients resuscitated from an OHCA with multivessel coronary disease.
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Affiliation(s)
- Vilma Kajana
- Division of Cardiology, Fondazione IRCCS Policlinico San Matteo, Viale Golgi 19, 27100 Pavia, Italy
- Humanitas Mater Domini, 21053 Castellanza, Italy
| | - Enrico Baldi
- Division of Cardiology, Fondazione IRCCS Policlinico San Matteo, Viale Golgi 19, 27100 Pavia, Italy
- Correspondence: ; Tel.: +39-038-2501276
| | - Francesca Romana Gentile
- Division of Cardiology, Fondazione IRCCS Policlinico San Matteo, Viale Golgi 19, 27100 Pavia, Italy
- Department of Molecular Medicine, University of Pavia, 27100 Pavia, Italy
| | - Sara Compagnoni
- Division of Cardiology, Fondazione IRCCS Policlinico San Matteo, Viale Golgi 19, 27100 Pavia, Italy
- Department of Molecular Medicine, University of Pavia, 27100 Pavia, Italy
| | - Federico Quilico
- Division of Cardiology, Fondazione IRCCS Policlinico San Matteo, Viale Golgi 19, 27100 Pavia, Italy
- Department of Molecular Medicine, University of Pavia, 27100 Pavia, Italy
| | - Luca Vicini Scajola
- Division of Cardiology, Fondazione IRCCS Policlinico San Matteo, Viale Golgi 19, 27100 Pavia, Italy
- Department of Molecular Medicine, University of Pavia, 27100 Pavia, Italy
| | - Alessandra Repetto
- Division of Cardiology, Fondazione IRCCS Policlinico San Matteo, Viale Golgi 19, 27100 Pavia, Italy
| | | | - Marco Ferlini
- Division of Cardiology, Fondazione IRCCS Policlinico San Matteo, Viale Golgi 19, 27100 Pavia, Italy
| | - Barbara Marinoni
- Division of Cardiology, Fondazione IRCCS Policlinico San Matteo, Viale Golgi 19, 27100 Pavia, Italy
| | | | - Roberto Primi
- Division of Cardiology, Fondazione IRCCS Policlinico San Matteo, Viale Golgi 19, 27100 Pavia, Italy
| | - Sara Bendotti
- Division of Cardiology, Fondazione IRCCS Policlinico San Matteo, Viale Golgi 19, 27100 Pavia, Italy
| | - Alessia Currao
- Division of Cardiology, Fondazione IRCCS Policlinico San Matteo, Viale Golgi 19, 27100 Pavia, Italy
| | - Simone Savastano
- Division of Cardiology, Fondazione IRCCS Policlinico San Matteo, Viale Golgi 19, 27100 Pavia, Italy
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21
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Zheng W, Huang X, Zhao X, Gong W, Wang X, Nie S. Impact of Stress Hyperglycemia on the Timing of Complete Revascularization in Non-diabetes Patients with ST Elevation Myocardial Infarction and Multivessel Disease. Angiology 2022; 74:587-595. [PMID: 35854437 DOI: 10.1177/00033197221115555] [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] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Background: Stress hyperglycemia (SHG) is related to an increased risk of mortality in diabetic patients with ST elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (PPCI). However, data are limited in non-diabetic patients especially in patients with multivessel disease (MVD). Methods and Results: In this retrospective study, 742 non-diabetic patients with STEMI and MVD were divided into SHG group and non-SHG group. The overall incidence of SHG was 24.9%. The incidence of no-reflow (NR) phenomenon (18.4% vs 11.8%; P = .024) and in-hospital mortality (1.6% vs .2%; P = .020) in SHG group were significantly higher than those in non-SHG group. SHG was associated with 30-day MACE (hazard ratio, 4.265; 95% confidence interval (CI), 1.354-13.439; P = .013), but not 1-year. Multivariate logistic analysis showed that SHG (odds ratio: 1.691, 95% CI: 1.072-2.667, P = .024) was an independent predictor of NR. If complete revascularization (CR) was performed during PPCI, the incidence of NR would be significantly higher. Conclusion: In non-diabetic patients with STEMI and MVD, SHG is associated with increased SF-NR and short-term adverse events, and CR during PPCI further increases the risk of NR.
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Affiliation(s)
- Wen Zheng
- Department of Cardiology 12667Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Xin Huang
- Department of Cardiology, 117968Beijing Shijitan Hospital, Capital Medical University, Beijing, China
| | - Xuedong Zhao
- Department of Cardiology 12667Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Wei Gong
- Department of Cardiology 12667Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Xiao Wang
- Department of Cardiology 12667Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Shaoping Nie
- Department of Cardiology 12667Beijing Anzhen Hospital, Capital Medical University, Beijing, China
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22
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Okuya Y, Gohil K, Moussa ID. Angiography versus FFR guided complete revascularization versus culprit-only revascularization for patients presenting with STEMI: Network meta-analysis. Catheter Cardiovasc Interv 2022; 100:340-350. [PMID: 35789058 DOI: 10.1002/ccd.30304] [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: 01/07/2022] [Revised: 04/17/2022] [Accepted: 06/05/2022] [Indexed: 11/07/2022]
Abstract
This study aimed to compare the outcomes of different revascularization strategies among patients presenting with ST-segment elevation myocardial infarction (STEMI) and multivessel coronary artery disease (MVD) undergoing primary percutaneous coronary intervention (PCI). MVD is present in about one-half of patients presenting with STEMI. Despite several randomized controlled trials (RCTs) comparing complete revascularization (CR) and culprit-only revascularization (COR), the optimal PCI strategy for STEMI patients with MVD remains unsettled. Moreover, it is unclear whether angiography-guided CR or fractional flow reserve (FFR)-guided CR is associated with better outcomes. PubMed, Scopus, and Cochrane Library were searched for RCTs comparing CR strategies with COR strategy in patients with STEMI between January 1, 2000 and September 30, 2021 were identified. A frequentist network meta-analyses were performed for three PCI strategies: (1) COR; (2) angiography-guided CR; and (3) FFR-guided CR. Ten RCTs including 7979 patients were included. A strategy of angiography-guided CR or FFR-guided CR was associated with a significantly lower rate of major adverse cardiac events (MACE) and unplanned revascularization compared with COR. Although there were no statistical significant difference between angiography-guided CR and FFR-guided CR, P score analysis showed that angiography-guided CR was ranked as the best strategy for reducing MACE, all-cause mortality, cardiovascular death, recurrent myocardial infarction, and unplanned revascularization. In patients presenting with STEMI and MVD undergoing primary PCI, angiography-guided CR or FFR-guided CR improve outcomes compared with COR. Furthermore, the strategy of angiography-guided CR ranked as the best revascularization strategy in those patients.
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Affiliation(s)
- Yoshiyuki Okuya
- Department of Clinical Sciences, Heart and Vascular Institute, Carle Health, Urbana, Illinois, USA.,Department of Clinical Sciences, Carle Illinois College of Medicine, University of Illinois, Urbana, Illinois, USA
| | - Kavita Gohil
- Department of Clinical Sciences, Stephens Family Clinical Research Institute, Carle Health, Urbana, Illinois, USA
| | - Issam D Moussa
- Department of Clinical Sciences, Heart and Vascular Institute, Carle Health, Urbana, Illinois, USA.,Department of Clinical Sciences, Carle Illinois College of Medicine, University of Illinois, Urbana, Illinois, USA
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Elbadawi A, Dang AT, Hamed M, Eid M, Prakash Hiriyur Prakash M, Saleh M, Gad M, Mamas MA, Rahman F, Elgendy IY. FFR- Versus Angiography-Guided Revascularization for Nonculprit Stenosis in STEMI and Multivessel Disease: A Network Meta-Analysis. JACC Cardiovasc Interv 2022; 15:656-666. [PMID: 35331458 DOI: 10.1016/j.jcin.2022.01.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [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: 09/17/2021] [Revised: 12/02/2021] [Accepted: 01/04/2022] [Indexed: 12/30/2022]
Abstract
OBJECTIVES The aim of this study was to examine the efficacy and safety of fractional flow reserve (FFR)-guided versus angiography-guided approaches for nonculprit stenosis among patients with acute ST-segment elevation myocardial infarction (STEMI) and multivessel disease. BACKGROUND The optimal strategy to guide revascularization of nonculprit stenosis among patients with STEMI and multivessel disease remains uncertain. METHODS Electronic databases were searched for randomized trials evaluating the outcomes of culprit-only revascularization, angiography-guided complete revascularization (CR), or FFR-guided CR. A pairwise meta-analysis comparing CR versus culprit-only revascularization and a network meta-analysis comparing the different revascularization techniques were conducted. The primary outcome was major adverse cardiac events (MACE). RESULTS The analysis included 11 trials with 8,195 patients. CR (ie, angiography-guided or FFR-guided CR) was associated with a lower incidence of MACE (odds ratio [OR]: 0.46; 95% CI: 0.35 to 0.59), cardiovascular mortality (OR: 0.63; 95% CI: 0.41 to 0.98), recurrent myocardial infarction (OR: 0.67; 95% CI: 0.48 to 0.95), and repeat ischemia-driven revascularization (OR: 0.26; 95% CI: 0.19 to 0.35). Network meta-analysis demonstrated that the incidence of MACE was lower with both angiography-guided CR (OR: 0.43; 95% CI: 0.31 to 0.58) and FFR-guided CR (OR: 0.52; 95% CI: 0.35 to 0.78) compared with a culprit-only approach, while there was no difference in risk for MACE between angiography-guided and FFR-guided CR (OR: 0.81; 95% CI: 0.51 to 1.29). CONCLUSIONS Among patients with STEMI and multivessel disease, CR, with angiographic or FFR guidance for nonculprit stenosis, was associated with lower incidence of adverse events compared with culprit-only revascularization. FFR-guided CR was not superior to angiography-guided CR in reducing the incidence of adverse events. Future studies investigating other tools to risk-stratify nonculprit stenoses are encouraged.
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Affiliation(s)
- Ayman Elbadawi
- Division of Cardiology, Baylor College of Medicine, Houston, Texas, USA
| | - Alexander T Dang
- Department of Internal Medicine, University of Texas Medical Branch, Galveston, Texas, USA
| | - Mohamed Hamed
- Department of Internal Medicine, Florida Atlantic University, Boca Raton, Florida
| | - Mennaallah Eid
- Department of Internal Medicine, Lincoln Medical Center, New York, New York, USA
| | | | - Mohammed Saleh
- Department of Cardiovascular Medicine, University of Texas Medical Branch, Galveston, Texas, USA
| | - Mohamed Gad
- Department of Internal Medicine, Cleveland Clinic, Cleveland, Ohio, USA
| | - Mamas A Mamas
- Keele Cardiovascular Research Group, Centre for Prognosis Research, Keele University, Keele, United Kingdom; Department of Cardiology, Royal Stoke University Hospital, Stoke-on-Trent, United Kingdom
| | - Faisal Rahman
- Division of Cardiology, Baylor College of Medicine, Houston, Texas, USA
| | - Islam Y Elgendy
- Department of Medicine, Weill Cornell Medicine-Qatar, Doha, Qatar.
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Ferrante G, Barbieri L, Sponzilli C, Lucreziotti S, Salerno Uriarte D, Centola M, Verdoia M, Carugo S. Predictors of Mortality and Long-Term Outcome in Patients with Anterior STEMI: Results from a Single Center Study. J Clin Med 2021; 10:5634. [PMID: 34884341 DOI: 10.3390/jcm10235634] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2021] [Revised: 11/22/2021] [Accepted: 11/26/2021] [Indexed: 12/28/2022] Open
Abstract
Anterior ST segment elevation myocardial infarction (A-STEMI) has the worst prognosis among all infarct sites due to larger infarct size and the higher cardiac enzyme release. We retrospectively analyzed 584 A-STEMI undergoing urgent coronary angiography from October 2008 to April 2019. The median follow-up time was 1774 days with a minimum of a 1-year follow-up for 498 patients. In-hospital mortality was 8.6%, while long-term, all-cause mortality and 1-year mortality were 18.8% and 6.8%, respectively. The main predictors for in-hospital mortality were ejection fraction (LV-EF), baseline estimated glomerular filtration rate (eGFR), female gender and cardiogenic shock (CS) at admission, while long-term predictors of mortality were age, coronary artery disease (CAD) extension and LV-EF. Patients presenting with CS (6.5%) showed a higher mortality rate (in-hospital 68.4%, long term 41.7%). Among 245 patients (42%) with multivessel disease (MVD), complete revascularization (CR) during the index procedure was performed in 42.8% of patients and more often in patients with CS at admission (19.1% vs. 6.1%, p = 0.008). Short- and long-term mortality were not significantly influenced by the revascularization strategy (CR/culprit only). Our study confirmed the extreme fragility of A-STEMI patients, especially in case of CS at admission. LV-EF is a powerful predictor of a poor outcome. In MVD, CR during p-PCI did not show any advantage for either long- or short-term mortality compared to the culprit-only strategy.
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Zhao L, Guo W, Huang W, Wang L, Mo F, Chen X, Li C, Huang S. Comparative Effectiveness of Complete Revascularization Strategies in Patients With ST-Segment Elevation Myocardial Infarction and Multivessel Disease: A Bayesian Network Meta-Analysis. Front Cardiovasc Med 2021; 8:724274. [PMID: 34631826 PMCID: PMC8496298 DOI: 10.3389/fcvm.2021.724274] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2021] [Accepted: 08/10/2021] [Indexed: 11/30/2022] Open
Abstract
Whether fractional flow reserve (FFR) should be available for revascularization in patients with ST-segment elevation myocardial infarction (STEMI) and multivessel disease (MVD) is controversial. We aimed to compare the efficacy of various complete revascularization (CR) regimens for STEMI patients with MVD. The PubMed and Cochrane Library databases and clinicaltrial.gov were searched for the randomized controlled trials (RCTs) comparing the FFR-guided CR, angiography-guided CR, and culprit-only revascularization (COR) strategies in STEMI patients with MVD. A Bayesian random-effect model was employed to synthesize the evidence in network meta-analysis. We used relative risk (RR) and 95% credible interval (CrI) as measures of effect size. The primary endpoint was the composite outcome of all-cause mortality or myocardial infarction (MI). Twelve RCTs were included. Angiography-guided CR showed a lower event rate of the composite outcome (RR, 0.68; 95%CrI, 0.50–0.87), all-cause mortality (RR, 0.75; 95%CrI, 0.55–0.96), MI (RR, 0.63; 95%CrI, 0.43–0.86), and repeat revascularization (RR, 0.36; 95% CrI, 0.24–0.55) compared with COR. Additionally, angiography-guided CR had a lower risk of primary outcome (RR, 0.64; 95%CrI, 0.38–0.94) and MI (RR, 0.58; 95%CrI, 0.31–0.92) than FFR-guided CR. The difference between the FFR-guided CR and COR in terms of composite outcome, all-cause mortality, and MI was similar. Angiography-guided CR was associated with the highest probability of optimal treatment for the primary outcome (98.5%), followed by FFR-guided CR (1.2%) and COR (0.3%). STEMI patients with MVD benefitted more from angiography-guided CR than from FFR-guided CR. However, only one study compared the effectiveness of FFR-guided and angiography-guided PCI; thus, the comparison between FFR-guided and angiography-guided PCI relied on indirect evidence. Therefore, further studies directly comparing the effectiveness of these two CR strategies are warranted.
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Affiliation(s)
- Lingyue Zhao
- Huazhong University of Science and Technology Union Shenzhen Hospital, Shenzhen, China
| | - Wenqin Guo
- Department of Cardiology, Fuwai Hospital Chinese Academy of Medical Sciences, Shenzhen, China
| | - Weichao Huang
- Department of Cardiology, Fuwai Hospital Chinese Academy of Medical Sciences, Shenzhen, China
| | - Lili Wang
- Department of Cardiology, Fuwai Hospital Chinese Academy of Medical Sciences, Shenzhen, China
| | - Fanrui Mo
- Department of Cardiology, The Fourth Affiliated Hospital of Guangxi Medical University, Liuzhou, China
| | - Xiehui Chen
- Department of Cardiology, Shenzhen Longhua District Central Hospital, Shenzhen, China
| | - Chaoyang Li
- Huazhong University of Science and Technology Union Shenzhen Hospital, Shenzhen, China
| | - Siquan Huang
- People's Hospital of Longhua District, Shenzhen, China
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Zhang J, Yao M, Jia X, Feng H, Fu J, Tang W, Cong H. The efficacy and safety of quantitative flow ratio-guided complete revascularization in patients with ST-segment elevation myocardial infarction and multivessel disease: A pilot randomized controlled trial. Cardiol J 2021; 30:178-187. [PMID: 34581424 PMCID: PMC10129263 DOI: 10.5603/cj.a2021.0111] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Revised: 08/13/2021] [Accepted: 08/27/2021] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND In patients with ST-segment elevation myocardial infarction (STEMI) and multivessel disease (MVD), the treatment strategy for non-infarct-related artery (non-IRA) remains controversial. Quantitative flow ratio (QFR) is a new angiography-based physiological assessment index. However, there is little evidence on the practical clinical application of QFR. METHODS Two hundred and twenty-nine patients with STEMI and MVD were recruited for this study. Patients were randomly assigned to either receive QFR-guided complete revascularization (QFR-G-CR) of non-IRA or receive no further invasive treatment. The primary (1º) endpoint analyzed included death due to all causes, non-fatal myocardial infarction (MI), and ischemia-induced revascularization at 12 months post-surgery. Secondary (2º) endpoints included cardiovascular death, unstable angina, stent thrombosis, New York Heart Association (NYHA) class IV heart failure (HF), and stroke at 1 year post surgery. Massive bleeding and contrast-associated acute kidney injury (CAKI) were used as safety endpoints. RESULTS Around the 12 month follow up, the 1º outcome was recorded in 11/115 patients (9.6%) in the QFR-G-CR population, relative to 23/114 patients (20.1%) in the IRA-only PCI population (hazard ratio [HR]: 0.45; 95% confidence interval [CI]: 0.22-0.92; p = 0.025). Unstable angina in 6 (5.2%) and 16 (14.0%) patients (HR: 0.36; 95% CI: 0.14-0.92; p = 0.026), respectively. No marked alterations were found in the massive bleeding and CAKI categories. CONCLUSIONS In conclusion, STEMI and MVD patients can benefit from QFR-G-CR of non-IRA lesions in the initial stages of acute MI. This can help reduce incidences of major adverse cardiovascular events and unstable angina, relative to IRA treatment only. Chinese Clinical Trial Registration number: ChiCTR2100044120.
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Affiliation(s)
- Jing Zhang
- Department of Cardiology, Thoracic Clinical College, Tianjin Medical University, Tai'erzhuang Road, No.261, Jinnan District, Tianjin, 300222 Tianjin, China.,Department of Cardiology, Affiliated Hospital of Hebei University, 071000 Baoding, China
| | - Mingyan Yao
- Department of Endocrinology, Baoding NO.1 Central Hospital, 071000 Baoding, China
| | - Xinwei Jia
- Department of Cardiology, Affiliated Hospital of Hebei University, 071000 Baoding, China.
| | - Huiping Feng
- Department of Cardiology, Affiliated Hospital of Hebei University, 071000 Baoding, China
| | - Jingjing Fu
- Department of Cardiology, Fengfeng General Hospital, North China Medical and Health Group, 056000 Handan, China
| | - Wei Tang
- Department of Cardiology, Affiliated Hospital of Hebei University, 071000 Baoding, China
| | - Hongliang Cong
- Department of Cardiology, Thoracic Clinical College, Tianjin Medical University, Tai'erzhuang Road, No.261, Jinnan District, Tianjin, 300222 Tianjin, China
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Veiga Oliveira P, Madeira M, Ranchordás S, Marques M, Almeida M, Sousa-Uva M, Abecasis M, Neves JP. Complete surgical revascularization: Different definitions, same impact? J Card Surg 2021; 36:4497-4502. [PMID: 34533240 DOI: 10.1111/jocs.15986] [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] [Subscribe] [Scholar Register] [Received: 03/14/2021] [Revised: 08/19/2021] [Accepted: 08/21/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND There are several different definitions of complete revascularization on coronary surgery across the literature. Despite the importance of this definition, there is no agreement on which one has the most impact. The aim of this study was to evaluate which definition of complete surgical revascularization correlates with early and late outcomes. METHODS All consecutive patients submitted to isolated CABG from 2012 to 2016 with previous myocardial scintigraphy were evaluated. EXCLUSION CRITERIA emergent procedures and previous cardiac surgery procedures. The population of 162 patients, follow-up complete in 100% patients; median 5.5; IQR: 4.4-6.9 years. Each and all of the 162 patients were classified as complying or not with the four different definitions: numerical, functional, anatomical conditional, and anatomical unconditional. Perioperative outcome: MACCE; long-term outcomes: survival and repeat revascularization. Univariable and multivariable analyses were developed to detect predictors of outcomes. RESULTS Complete functional revascularization was a predictor of increased survival (HR: 0.47; CI 95: 0.226-0.969; p = .041). No other definitions showed effect on follow-up mortality. Age and cardiac dysfunction increased long-term mortality. The definition of complete revascularization did not have an impact on MACCE or the need for revascularization CONCLUSIONS: A uniformly accepted definition of complete coronary revascularization is lacking. This study raises awareness about the importance of viability guidance for CABG.
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Affiliation(s)
| | - Márcio Madeira
- Department of Cardiothoracic Surgery, Santa Cruz Hospital, Lisbon, Portugal
| | - Sara Ranchordás
- Department of Cardiothoracic Surgery, Santa Cruz Hospital, Lisbon, Portugal
| | - Marta Marques
- Department of Cardiothoracic Surgery, Santa Cruz Hospital, Lisbon, Portugal
| | - Manuel Almeida
- Department of Cardiology, Santa Cruz Hospital, Lisbon, Portugal
| | - Miguel Sousa-Uva
- Department of Cardiothoracic Surgery, Santa Cruz Hospital, Lisbon, Portugal
| | - Miguel Abecasis
- Department of Cardiothoracic Surgery, Santa Cruz Hospital, Lisbon, Portugal
| | - José Pedro Neves
- Department of Cardiothoracic Surgery, Santa Cruz Hospital, Lisbon, Portugal
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Moses JW, Prasad M. Are All Total Occlusions Created Equal?: Striving for Complete Revascularization While Differentiating Apples From Oranges. J Am Coll Cardiol 2021; 77:541-3. [PMID: 33538251 DOI: 10.1016/j.jacc.2020.12.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Accepted: 12/01/2020] [Indexed: 11/23/2022]
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Li LF, Qiu M, Liu SY, Zhou HR. Effects of patient characteristics on the efficacy of complete revascularization for treatment of ST-segment elevation myocardial infarction with multivessel disease: A meta-analysis. Medicine (Baltimore) 2021; 100:e26251. [PMID: 34160388 PMCID: PMC8238282 DOI: 10.1097/md.0000000000026251] [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] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2020] [Accepted: 05/19/2021] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND Several randomized controlled trials (RCTs) have evaluated the efficacy of complete vs culprit-only revascularization for treatment of ST-segment elevation myocardial infarction (STEMI) with multivessel disease. However, the efficacy of complete revascularization vs culprit-only revascularization in some STEMI patient subgroups remains unclear. METHODS We searched PubMed and Embase for related RCTs from the start date of databases to January 3, 2020. The endpoint assessed in this meta-analysis was major adverse cardiac events (MACE). Random-effects meta-analysis was conducted stratified by each of the 5 factors of interest (i.e., sex, age, history of diabetes, ECG infarct location, and the number of arteries with stenosis) to estimate pooled hazard ratio and 95% confidence interval. Random-effects meta-regression was conducted to assess subgroup differences. We examined publication bias by drawing funnel plots and performing Egger test. This meta-analysis is reported according to the PRISMA statement. RESULTS Six RCTs were included for pooled analysis. Compared with culprit-only revascularization, complete revascularization significantly reduced the risk of MACE (hazard ratio 0.48, 95% confidence interval 0.42-0.55; I2 = 0%; P for relative effect < .001). This significant reduction in the risk of MACE exhibited by complete revascularization was observed in most of the subgroups of interest. All of the subgroup effects based on the 5 factors of interest were not statistically significant (Psubgroup ranged from 0.198 to 0.556). Publication bias was not suggested by funnel plots and Egger test. CONCLUSIONS Compared with culprit-only revascularization, complete revascularization significantly reduces the MACE risk in patients with STEMI and multivessel disease, which is independent of sex, age, history of diabetes, ECG infarct location, and the number of arteries with stenosis.
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Affiliation(s)
- Lu-Feng Li
- Department of General Medicine, Shenzhen Longhua District Central Hospital, Shenzhen
| | - Mei Qiu
- Department of General Medicine, Shenzhen Longhua District Central Hospital, Shenzhen
| | - Shu-Yan Liu
- Department of Cardiology, The Second Affiliated Hospital of Kunming Medical University, Kunming, China
| | - Hai-Rong Zhou
- Department of General Medicine, Shenzhen Longhua District Central Hospital, Shenzhen
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30
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Bianco V, Kilic A, Aranda-Michel E, Serna-Gallegos D, Ferdinand F, Dunn-Lewis C, Wang Y, Thoma F, Navid F, Sultan I. Complete revascularization during coronary artery bypass grafting is associated with reduced major adverse events. J Thorac Cardiovasc Surg 2021:S0022-5223(21)00900-4. [PMID: 34272071 DOI: 10.1016/j.jtcvs.2021.05.046] [Citation(s) in RCA: 4] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2020] [Revised: 04/26/2021] [Accepted: 05/24/2021] [Indexed: 10/21/2022]
Abstract
OBJECTIVE Complete revascularization literature is limited by variance in patient cohorts and inconsistent definitions. The objective of the current study was to provide risk-adjusted outcomes for complete revascularization of significant nonmain-branch and main-branch vessel stenoses. METHODS All patients that underwent first-time isolated coronary artery bypass grafting procedures were included. Kaplan-Meier survival estimates, cumulative incidence function, and Cox regression were used to analyze outcomes. RESULTS The total population consisted of 3356 patients that underwent first-time isolated coronary artery bypass grafting. Eight hundred eighty-nine (26.5%) patients had incomplete and 2467 (73.5%) had complete revascularization. For main-branch vessels, 677 (20.2%) patients had incomplete revascularization and 2679 (79.8%) were completely revascularized. Following risk adjustment with inverse probability treatment weighting, all baseline characteristics were balanced (standardized mean difference, ≤ 0.10). On Kaplan-Meier estimates, survival at 1 year (94.6% vs 92.5%) and 5 years (86.5% vs 82.1%) (P = .05) was significantly better for patients who received complete revascularization. Freedom from major adverse cardiac and cerebrovascular events was significantly higher for the complete revascularization cohort at both 1 year (89.2% vs 84.2%) and 5 years (72.5% vs 66.7%) (P < .001). Complete revascularization (hazard ratio, 0.82; 95% confidence interval, 0.70-0.95; P = .01) was independently associated with a significant reduction in major adverse cardiac and cerebrovascular events. Incomplete revascularization of nonmain-branch vessels was not associated with mortality (hazard ratio, 1.14; 95% confidence interval, 0.74-1.8; P = .55) or major adverse cardiac and cerebrovascular events (hazard ratio, 0.90; 95% confidence interval, 0.66-1.24; P = .52). CONCLUSIONS Complete surgical revascularization of all angiographically stenotic vessels in patients with multivessel coronary artery disease is associated with fewer major adverse events. Incomplete revascularization of nonmain-branch vessels is not associated with survival or major adverse cardiac and cerebrovascular events.
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Affiliation(s)
- Valentino Bianco
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pa
| | - Arman Kilic
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pa; Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pa
| | - Edgar Aranda-Michel
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pa
| | - Derek Serna-Gallegos
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pa; Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pa
| | - Francis Ferdinand
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pa; Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pa
| | - Courtenay Dunn-Lewis
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pa
| | - Yisi Wang
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pa
| | - Floyd Thoma
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pa
| | - Forozan Navid
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pa; Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pa
| | - Ibrahim Sultan
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pa; Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pa.
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Iqbal MB. Nonculprit Disease in Non-ST-Segment Elevation Myocardial Infarction and Cardiogenic Shock. JACC Cardiovasc Interv 2021; 14:1079-1081. [PMID: 33933389 DOI: 10.1016/j.jcin.2021.03.064] [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: 02/24/2021] [Revised: 03/15/2021] [Accepted: 03/30/2021] [Indexed: 11/20/2022]
Affiliation(s)
- M Bilal Iqbal
- Victoria Heart Institute Foundation, Victoria, British Columbia, Canada; Royal Jubilee Hospital, Victoria, British Columbia, Canada; Centre for Cardiovascular Innovation, University of British Columbia, British Columbia, Canada.
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32
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Iqbal MB, Moore PT, Nadra IJ, Robinson SD, Fretz E, Ding L, Fung A, Aymong E, Chan AW, Hodge S, Webb J, Sheth T, Jolly SS, Mehta SR, Sathananthan J, Wood DA, Della Siega A. Complete revascularization in stable multivessel coronary artery disease: A real world analysis from the British Columbia Cardiac Registry. Catheter Cardiovasc Interv 2021; 99:627-638. [PMID: 33660326 DOI: 10.1002/ccd.29564] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2020] [Revised: 01/24/2021] [Accepted: 02/06/2021] [Indexed: 11/10/2022]
Abstract
BACKGROUND More than half of patients undergoing percutaneous coronary intervention (PCI) have multivessel disease (MVD). The prognostic significance of PCI in stable patients has recently been debated, but little data exists about the potential benefit of complete revascularization (CR) in stable MVD. We investigated the prognostic benefit of CR in patients undergoing PCI for stable disease. METHODS We compared CR versus incomplete revascularization (IR) in 8,436 patients with MVD. The primary outcome was all-cause mortality at 5 years. RESULTS A total of 1,399 patients (17%) underwent CR during the index PCI procedure for stable disease. CR was associated with lower mortality (6.2 vs. 10.7%, p < .001) and lower repeat revascularization at 5 years (12.7 vs. 18.4%, p < .001). Multivariable-adjusted analyses indicated that CR was associated with lower mortality (HR = 0.73, 95% CI: 0.58-0.91, p = .005) and repeat revascularization at 5 years (HR = 0.78, 95% CI: 0.66-0.93, p = .005). These findings were also confirmed in propensity-matched cohorts. Subgroup analyses indicated that CR conferred survival in older patients, male patients, absence of renal disease, greater angina (CCS Class III-IV) and heart failure (NYHA Class III-IV) symptoms, and greater burden of coronary disease. In sensitivity analyses where patients with subsequent repeat revascularization events were excluded, CR remained a strong predictor for lower mortality (HR = 0.69, 95% CI: 0.54-0.89, p = .004). CONCLUSIONS In this study of stable patients with MVD, CR was an independent predictor of long-term survival. This benefit was specifically seen in higher risk patient groups and indicates that CR may benefit selected stable patients with MVD.
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Affiliation(s)
- M Bilal Iqbal
- Victoria Heart Institute Foundation, Victoria, British Columbia, Canada.,Royal Jubilee Hospital, Victoria, British Columbia, Canada.,Centre for Cardiovascular Innovation, University of British Columbia, Vancouver, British Columbia, Canada
| | - Peter T Moore
- Victoria Heart Institute Foundation, Victoria, British Columbia, Canada.,Royal Jubilee Hospital, Victoria, British Columbia, Canada
| | - Imad J Nadra
- Victoria Heart Institute Foundation, Victoria, British Columbia, Canada.,Royal Jubilee Hospital, Victoria, British Columbia, Canada
| | - Simon D Robinson
- Victoria Heart Institute Foundation, Victoria, British Columbia, Canada.,Royal Jubilee Hospital, Victoria, British Columbia, Canada.,Centre for Cardiovascular Innovation, University of British Columbia, Vancouver, British Columbia, Canada
| | - Eric Fretz
- Victoria Heart Institute Foundation, Victoria, British Columbia, Canada.,Royal Jubilee Hospital, Victoria, British Columbia, Canada
| | - Lillian Ding
- Provincial Health Services Authority, Vancouver, British Columbia, Canada
| | - Anthony Fung
- Vancouver General Hospital, Vancouver, British Columbia, Canada
| | - Eve Aymong
- St. Paul's Hospital, Vancouver, British Columbia, Canada
| | - Albert W Chan
- Centre for Cardiovascular Innovation, University of British Columbia, Vancouver, British Columbia, Canada.,Royal Columbian Hospital, Vancouver, British Columbia, Canada
| | - Steven Hodge
- Centre for Cardiovascular Innovation, University of British Columbia, Vancouver, British Columbia, Canada.,Kelowna General Hospital, Kelowna, British Columbia, Canada
| | - John Webb
- Centre for Cardiovascular Innovation, University of British Columbia, Vancouver, British Columbia, Canada.,St. Paul's Hospital, Vancouver, British Columbia, Canada
| | - Tej Sheth
- Population Health Research Institute, Hamilton, Ontario, Canada
| | - Sanjit S Jolly
- Population Health Research Institute, Hamilton, Ontario, Canada
| | - Shamir R Mehta
- Population Health Research Institute, Hamilton, Ontario, Canada
| | - Janarthanan Sathananthan
- Centre for Cardiovascular Innovation, University of British Columbia, Vancouver, British Columbia, Canada.,Vancouver General Hospital, Vancouver, British Columbia, Canada
| | - David A Wood
- Centre for Cardiovascular Innovation, University of British Columbia, Vancouver, British Columbia, Canada.,Vancouver General Hospital, Vancouver, British Columbia, Canada
| | - Anthony Della Siega
- Victoria Heart Institute Foundation, Victoria, British Columbia, Canada.,Royal Jubilee Hospital, Victoria, British Columbia, Canada.,Centre for Cardiovascular Innovation, University of British Columbia, Vancouver, British Columbia, Canada
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Abdelnabi M, Zaki M, Sadaka M, Nawar M. Effects of coronary revascularization by elective percutaneous coronary intervention on cardiac autonomic modulation assessed by heart rate variability: a single-center prospective cohort study. Am J Cardiovasc Dis 2021; 11:164-175. [PMID: 33815932 PMCID: PMC8012296] [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] [Subscribe] [Scholar Register] [Received: 12/24/2020] [Accepted: 01/29/2021] [Indexed: 06/12/2023]
Abstract
OBJECTIVE To study the effects of coronary revascularization using elective percutaneous coronary intervention (PCI) on autonomic modulation assessed by heart rate variability measurement (HRV) in coronary artery disease (CAD) patients. METHODS A single-center prospective cohort study included 100 patients were included undergoing elective PCI excluding those with contraindication to contrast or dual antiplatelet therapy, atrial fibrillation or multiple premature beats, receiving anti-arrhythmic drugs and those who underwent previous PCI or coronary artery bypass graft (CABG). Short-term measurement of time domain parameters (mean, SDNN, RMSSD) and frequency domain parameters (LF component, HF component, LF/HF ratio) of HRV was performed at the same time of the day, pre-PCI, 24 hours and 6 months post-PCI by CheckMyheart™ handheld HRV device. 5-min HRV analysis software was used to interpret the data using standard methods of HRV measurement of the Task Force of The European Society of Cardiology (ESC) and The North American Society of Pacing and Electrophysiology. SYNTAX (SX) score was calculated before PCI and residual SYNTAX (rSS) score was calculated after PCI using SYNTAX score calculator software. RESULTS The mean age of the studied population was 56.89±10.75 years with 85% males. HRV time and frequency domain parameters showed a statistically significant improvement at different time intervals (before PCI, 24 hours and 6 months after PCI) (p-value <0.001). HRV time and frequency domain measures showed a statistically significant difference between time and frequency domain HRV parameters 24 hours and 6 months after PCI in patients who had complete revascularization (CR) with those who had incomplete revascularization (IR). (p-value <0.001). CONCLUSION Autonomic modulation in CAD patients was improved by coronary revascularization using PCI assessed by serial HRV measurement. Patients with CR had better autonomic modulation than those with IR assessed by HRV 24 and 6 months after PCI.
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Affiliation(s)
- Mahmoud Abdelnabi
- Cardiology and Angiology Unit, Clinical and Experimental Internal Medicine Department, Medical Research Institute, Alexandria UniversityAlexandria, Egypt
| | - Moataz Zaki
- Cardiology and Angiology Unit, Clinical and Experimental Internal Medicine Department, Medical Research Institute, Alexandria UniversityAlexandria, Egypt
| | - Mohamed Sadaka
- Cardiology Department, Faculty of Medicine, Alexandria UniversityAlexandria, Egypt
| | - Moustafa Nawar
- Cardiology Department, Faculty of Medicine, Alexandria UniversityAlexandria, Egypt
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Zhang L, Fu Y, Gong Y, Zhao H, Wu S, Yang H, Zhang Z, Ling Y. Graft patency and completeness of revascularization in minimally invasive multivessel coronary artery bypass surgery. J Card Surg 2021; 36:992-997. [PMID: 33533054 DOI: 10.1111/jocs.15345] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2020] [Revised: 11/25/2020] [Accepted: 12/08/2020] [Indexed: 11/28/2022]
Abstract
OBJECTIVES Graft patency and completeness of revascularization were analyzed in patients who underwent off-pump minimally invasive coronary artery bypass grafting via a left small thoracotomy. METHODS We retrospectively reviewed the invasive angiography findings and clinical data of 186 consecutive patients who underwent off-pump minimally invasive coronary artery bypass grafting via a left small thoracotomy. The left internal thoracic artery and saphenous vein were used to bypass two or more of three coronary artery systems: the left anterior descending artery, left circumflex artery, or right coronary artery. Before hospital discharge, invasive angiography was performed to assess graft patency. Clinical variables during hospitalization and follow-up were collected and analyzed. RESULTS All 186 patients successfully underwent off-pump minimally invasive coronary artery bypass grafting without conversion to sternotomy or assistance of cardiopulmonary bypass. The mean graft number was 2.81 per patient (range, 2-5), and the total number of grafts was 522. The in-hospital mortality rate was 1.6% (3 of 186). A total of 181 of 186 (97.3%) patients underwent postoperative invasive angiography. Among the 510 grafts assessed by angiography, the total graft patency rate was 96.3% (491 of 510) (98.3% [171 of 174] for left internal thoracic artery grafts and 95.2% [318 of 334] for saphenous vein grafts). The rate of complete revascularization was 99.5% (185 of 186). CONCLUSIONS Minimally invasive coronary artery bypass grafting using left internal thoracic artery and saphenous vein grafts provides acceptable graft patency and completeness of revascularization for selected patients with multivessel disease.
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Affiliation(s)
- Lufeng Zhang
- Department of Cardiovascular Surgery, Peking University Third Hospital, Beijing, China
| | - Yuanhao Fu
- Department of Cardiovascular Surgery, Peking University Third Hospital, Beijing, China
| | - Yichen Gong
- Department of Cardiovascular Surgery, Peking University Third Hospital, Beijing, China
| | - Hong Zhao
- Department of Cardiovascular Surgery, Peking University Third Hospital, Beijing, China
| | - Song Wu
- Department of Cardiovascular Surgery, Peking University Third Hospital, Beijing, China
| | - Hang Yang
- Department of Cardiovascular Surgery, Peking University Third Hospital, Beijing, China
| | - Zhe Zhang
- Department of Cardiovascular Surgery, Peking University Third Hospital, Beijing, China
| | - Yunpeng Ling
- Department of Cardiovascular Surgery, Peking University Third Hospital, Beijing, China
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Bainey KR, Alemayehu W, Armstrong PW, Westerhout CM, Kaul P, Welsh RC. Long-Term Outcomes of Complete Revascularization With Percutaneous Coronary Intervention in Acute Coronary Syndromes. JACC Cardiovasc Interv 2020; 13:1557-67. [PMID: 32646697 DOI: 10.1016/j.jcin.2020.04.034] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2019] [Revised: 02/25/2020] [Accepted: 04/14/2020] [Indexed: 12/17/2022]
Abstract
OBJECTIVES The aim of this study was to evaluate the long-term outcomes of patients with acute coronary syndromes (ACS) with multivessel disease undergoing percutaneous coronary intervention (PCI). BACKGROUND Controversy exists regarding the benefit of multivessel PCI across the spectrum of ACS. METHODS A total of 9,094 patients with ACS and multivessel disease (≥70% stenosis in 2 or more major epicardial vessels) undergoing PCI from the Alberta COAPT (Contemporary Acute Coronary Syndrome Patients Invasive Treatment Strategies) registry (April 1, 2007, to March 31, 2013) were reviewed. Comparisons were made between patients who underwent complete revascularization and those with incomplete revascularization. Complete revascularization was defined as multivessel PCI with a residual angiographic jeopardy score ≤10%. Associations between revascularization status and all-cause death or new myocardial infarction (primary composite endpoint) and all-cause death, new myocardial infarction, or repeat revascularization (secondary composite endpoint) were evaluated. RESULTS Of the study cohort, 66.0% underwent complete revascularization. Compared with incomplete revascularization, the primary composite endpoint occurred less frequently with complete revascularization (event rate within 5 years 15.4% vs. 22.2%; inverse probability-weighted hazard ratio [IPW-HR]: 0.78; 95% confidence interval [CI]: 0.73 to 0.84; p < 0.0001). The secondary composite endpoint was less likely to occur with complete revascularization (event rate within 5 years 23.3% vs. 37.5%; IPW-HR: 0.61; 95% CI: 0.58 to 0.65; p < 0.0001). Complete revascularization was associated with a reduction in all-cause death (IPW-HR: 0.79; 95% CI: 0.73 to 0.86; p = 0.0004), new myocardial infarction (IPW-HR: 0.76; 95% CI: 0.69 to 0.84; p < 0.0001), and repeat revascularization (IPW-HR: 0.53; 95% CI: 0.49 to 0.57; p < 0.0001). CONCLUSIONS Results from this large contemporary registry of patients with ACS and PCI for multivessel disease suggest that complete revascularization occurs commonly and is associated with improved clinical outcomes (including survival) within 5 years.
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Abstract
Chronic total occlusion (CTO) of a coronary artery is typically defined as a completely occluded artery without any antegrade flow and a duration of at least 3 months. We reviewed the current literature describing the optimal management of CTO including the role of revascularization and choice of modality, i.e., percutaneous coronary intervention (PCI) or coronary artery bypass graft surgery. Databases (PubMed, the Cochrane Library, Embase, EBSCO, Web of Science, and CINAHL) were searched and relevant studies of patients with CTO were selected for review. The prevalence of coronary artery CTOs is approximately 25% among patients undergoing coronary angiography for angina. Available data suggests that PCI of CTO can be a technically complex procedure with relatively lower success rates compared with non-CTO PCI and typically associated with a higher complication rate especially at nonspecialized centers. Furthermore, successful CTO-PCI is associated with symptomatic improvement but does not appear to improve mortality, myocardial infarction, stroke, and repeat revascularization rates. Based on contemporary data, PCI of CTO lesions may be considered in patients with incapacitating angina despite treatment with optimal guideline-directed medical therapy and in whom based on coronary anatomy there is a reasonable chance of technical success with an acceptable risk.
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Affiliation(s)
- Adriana Mares
- Division of Cardiology, Department of Internal Medicine, Texas Tech University Health Sciences Center El Paso, El Paso, Texas
| | - Debabrata Mukherjee
- Division of Cardiology, Department of Internal Medicine, Texas Tech University Health Sciences Center El Paso, El Paso, Texas
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Alaswad K, Alqarqaz M. Complete Revascularization in STEMI: Why, How, and When? JACC Cardiovasc Interv 2020; 13:1583-5. [PMID: 32646700 DOI: 10.1016/j.jcin.2020.05.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Accepted: 05/12/2020] [Indexed: 11/23/2022]
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Calcagno S, Infusino F, Salvi N, Taccheri T, Colantonio R, Bruno E, Birtolo LI, Severino P, Lavalle C, Pucci M, Sardella G, Mancone M, Fedele F. The Role of Ranolazine for the Treatment of Residual Angina beyond the Percutaneous Coronary Revascularization. J Clin Med 2020; 9:E2110. [PMID: 32635532 DOI: 10.3390/jcm9072110] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Revised: 06/04/2020] [Accepted: 07/01/2020] [Indexed: 11/16/2022] Open
Abstract
INTRODUCTION Despite a successful percutaneous coronary intervention (PCI), several studies reported that the recurrence of angina after revascularization, even complete, is a particularly frequent occurrence in the first year after PCI. METHODS The aim was to evaluate the efficacy of treatment with ranolazine in addition to conventional anti-ischemic therapy in patients who underwent coronary angiography for persistent/recurrent angina after PCI and residual ischemia only due to small branches not suitable for further revascularization. Forty-nine consecutive patients were included in our registry, adding the ranolazine (375 mg b.i.d) to optimal medical therapy (OMT). The Exercise ECG Test (EET) was performed in all patients before to start the therapy (baseline BL) and at 30 days (T1) after enrollment. RESULTS The average duration of the exercise was increased after the therapy with ranolazine comparing to baseline (RG 9'1'' ± 2' versus BL 8'10'' ± 2', p = 0.01). Seven (14.3%) patients after receiving ranolazine had not crossed the threshold of six minutes (75 watts) compared to 20 (40.8%) of BL (p = 0.0003). Stress angina appeared more frequently at BL than at 30 days (T1 4.1% versus BL 16.3%, p = 0.04) as well as exercise-induced arrhythmias (BL 30.6% versus T1 14.3%, p = 0.05). CONCLUSIONS The addition of ranolazine to standard anti-ischemic therapy showed a significant improvement in EET results after one month of therapy, including reduced exercise angina, increased exercise tolerance, and reduced exercise arrhythmias.
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Wood DA, Cairns JA, Wang J, Mehran R, Storey RF, Nguyen H, Meeks B, Kunadian V, Tanguay JF, Kim HH, Cheema A, Dehghani P, Natarajan MK, Jolly SS, Amerena J, Keltai M, James S, Hlinomaz O, Niemela K, AlHabib K, Lewis BS, Nguyen M, Sarma J, Dzavik V, Della Siega A, Mehta SR. Timing of Staged Nonculprit Artery Revascularization in Patients With ST-Segment Elevation Myocardial Infarction: COMPLETE Trial. J Am Coll Cardiol 2020; 74:2713-2723. [PMID: 31779786 DOI: 10.1016/j.jacc.2019.09.051] [Citation(s) in RCA: 77] [Impact Index Per Article: 19.3] [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] [Received: 09/13/2019] [Revised: 09/26/2019] [Accepted: 09/27/2019] [Indexed: 11/26/2022]
Abstract
BACKGROUND The COMPLETE (Complete vs Culprit-only Revascularization to Treat Multi-vessel Disease After Early PCI for STEMI) trial demonstrated that staged nonculprit lesion percutaneous coronary intervention (PCI) reduced major cardiovascular (CV) events in patients with ST-segment elevation myocardial infarction (STEMI) and multivessel coronary artery disease (CAD). OBJECTIVES The purpose of this study was to determine the effect of nonculprit-lesion PCI timing on major CV outcomes and also the time course of the benefit of complete revascularization. METHODS Following culprit-lesion PCI, 4,041 patients with STEMI and multivessel CAD were randomized to staged nonculprit-lesion PCI or culprit-lesion only PCI. Randomization was stratified according to investigator-planned timing of nonculprit-lesion PCI: during or after the index hospitalization. The first coprimary outcome was the composite of CV death or myocardial infarction (MI). In pre-specified analyses, hazard ratios (HRs) were calculated for each time stratum. Landmark analyses of the entire population were performed within 45 days and after 45 days. RESULTS For nonculprit-lesion PCI planned during the index hospitalization (actual time: median 1 day), CV death or MI was reduced with complete revascularization compared with culprit-lesion only PCI (HR: 0.77; 95% confidence interval [CI]: 0.59 to 1.00). For nonculprit lesion PCI planned to occur after hospital discharge (actual time: median 23 days), CV death or MI was also reduced with complete revascularization (HR: 0.69; 95% CI: 0.49 to 0.97; interaction p = 0.62). Landmark analyses demonstrated an HR of 0.86 (95% CI: 0.59 to 1.24) during the first 45 days and 0.69 (95% CI: 0.54 to 0.89) from 45 days to the end of follow-up for intended nonculprit lesion PCI versus culprit lesion only PCI. CONCLUSIONS Among STEMI patients with multivessel disease, the benefit of complete revascularization over culprit-lesion only PCI was consistent irrespective of the investigator-determined timing of nonculprit-lesion intervention. The benefit of complete revascularization on hard clinical outcomes emerged mainly over the long term.
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Affiliation(s)
- David A Wood
- Centre for Cardiovascular Innovation, St. Paul's and Vancouver General Hospitals, University of British Columbia, Vancouver, British Columbia, Canada.
| | - John A Cairns
- Centre for Cardiovascular Innovation, St. Paul's and Vancouver General Hospitals, University of British Columbia, Vancouver, British Columbia, Canada
| | - Jia Wang
- Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - 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
| | - Helen Nguyen
- Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - Brandi Meeks
- Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - Vijay Kunadian
- Institute of Cellular Medicine, Faculty of Medical Sciences, Newcastle University and Cardiothoracic Centre, Freeman Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, United Kingdom
| | | | - Hahn-Ho Kim
- St Mary's General Hospital, Kitchener, Ontario, Canada
| | - Asim Cheema
- St. Michael's Hospital, Toronto, Ontario, Canada
| | - Payam Dehghani
- Prairie Vascular Research Network, University of Saskatchewan, Regina, Saskatchewan, Canada
| | - Madhu K Natarajan
- Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - Sanjit S Jolly
- Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, Ontario, Canada
| | | | - Matyas Keltai
- Hungarian Institute of Cardiology, Budapest, Hungary
| | - Stefan James
- Uppsala Clinical Research Centre and Department of Medical Sciences, Uppsala, Sweden
| | - Ota Hlinomaz
- University Hospital St Anne, Brno, Czech Republic
| | - Kari Niemela
- Heart Centre, Tampere University Hospital, Tampere, Finland
| | - Khalid AlHabib
- Department of Cardiac Services, King Fahad Cardiac Center, Saudi Arabia
| | - Basil S Lewis
- Cardiovascular Clinical Research Institute, Lady Davis Carmel Medical Center, Haifa, Israel
| | - Michel Nguyen
- Division of Cardiology, Centre Hospitalier, Universitaire de Sherbrooke, Quebec, Quebec, Canada
| | - Jaydeep Sarma
- North West Heart Centre, Wythenshawe Hospital, Manchester, United Kingdom
| | - Vladimir Dzavik
- Peter Munk Cardiac Centre, University Health Network, Toronto, Ontario, Canada
| | - Anthony Della Siega
- Department of Cardiac Services, Victoria Heart Institute Foundation, Victoria, British Columbia, Canada
| | - Shamir R Mehta
- Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, Ontario, Canada.
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Agrawal H, Lange RA, Montanez R, Wali S, Mohammad KO, Kar S, Teleb M, Mukherjee D. The Role of Percutaneous Coronary Intervention in the Treatment of Chronic Total Occlusions: Rationale and Review of the Literature. Curr Vasc Pharmacol 2020; 17:278-290. [PMID: 29345588 DOI: 10.2174/1570161116666180117100635] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2017] [Revised: 12/29/2017] [Accepted: 01/02/2018] [Indexed: 12/26/2022]
Abstract
BACKGROUND Chronic total occlusion (CTO) of a coronary artery is defined as an occluded segment with no antegrade flow and a known or estimated duration of at least 12 weeks. OBJECTIVE We considered the current literature describing the indications and clinical outcomes for denovo CTO- percutaneous coronary intervention (PCI), and discuss the role of CTO-PCI and future directions for this procedure. METHODS Databases (PubMed, the Cochrane Library, Embase, EBSCO, Web of Science, and CINAHL were searched and relevant studies of CTO-PCI were selected for review. RESULTS The prevalence of coronary artery CTO's has been reported to be ~ 20% among patients undergoing diagnostic coronary angiography for suspected coronary artery disease. Revascularization of any CTO can be technically challenging and a time-consuming procedure with relatively low success rates and may be associated with a higher incidence of complications, particularly at non-specialized centers. However, with an increase in experience and technological advances, several centers are now reporting success rates above 80% for these lesions. There is marked variability among studies in reporting outcomes for CTO-PCI with some reporting potential mortality benefit, better quality of life and improved cardiac function parameters. Anecdotally, properly selected patients who undergo a successful CTO-PCI most often have profound relief of ischemic symptoms. Intuitively, it makes sense to revascularize an occluded coronary artery with the goal of improving cardiovascular function and patient quality of life. CONCLUSION CTO-PCI is a rapidly expanding specialized procedure in interventional cardiology and is reasonable or indicated if the occluded vessel is responsible for symptoms or in selected patients with silent ischemia in whom there is a large amount of myocardium at risk and PCI is likely to be successful.
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Affiliation(s)
- Harsh Agrawal
- Division of Interventional Cardiology, Department of Internal Medicine, St. Elizabeth's Medical Center, Tufts School of Medicine, Boston, MA 02135, United States
| | - Richard A Lange
- Department of Internal Medicine, Division of Cardiovascular Medicine, Texas Tech University, Paul L Foster School of Medicine, El Paso, Texas 79905, United States
| | - Ruben Montanez
- Department of Internal Medicine, Division of Cardiovascular Medicine, Texas Tech University, Paul L Foster School of Medicine, El Paso, Texas 79905, United States
| | - Soma Wali
- Department of Internal Medicine, University of California at Los Angeles, Olive View Medical Centre, David Geffen School of Medicine, Los Angeles, CA 90024, United States
| | - Khan Omar Mohammad
- Department of Internal Medicine, Division of Cardiovascular Medicine, Texas Tech University, Paul L Foster School of Medicine, El Paso, Texas 79905, United States
| | - Subrata Kar
- Department of Internal Medicine, Division of Cardiovascular Medicine, Texas Tech University, Paul L Foster School of Medicine, El Paso, Texas 79905, United States
| | - Mohamed Teleb
- Department of Internal Medicine, Division of Cardiovascular Medicine, Texas Tech University, Paul L Foster School of Medicine, El Paso, Texas 79905, United States
| | - Debabrata Mukherjee
- Department of Internal Medicine, Division of Cardiovascular Medicine, Texas Tech University, Paul L Foster School of Medicine, El Paso, Texas 79905, United States
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AlMaeen BN, ElMaghrby IS, AlNour MK, Alrefeidi TA, Abu Adas SM. Complete Revascularization of Reimplanted Talus After Isolated Total Talar Extrusion: A Case Report. Cureus 2020; 12:e7947. [PMID: 32377500 PMCID: PMC7199902 DOI: 10.7759/cureus.7947] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Total traumatic extrusion of the talus is a rare and disabling ankle injury. Treatment may include talar reimplantation or talar body removal, but an optimal treatment protocol has not yet been established. Several case reports showed that disruption of the vascular supply and contamination could lead to major complications, such as infection and avascular necrosis, with the high risk of these complications being associated with both the traumatic ankle injury itself and subsequent talar reimplantation. No report to date has described the revascularization of a completely extruded talus, as shown by serial MRI, a less invasive surgical strategy consisting of immediate reimplantation, early administration of antibiotics, and a short period of cast immobilization followed by early motion exercises. The present study describes complete revascularization and good clinical outcomes in a 30-year-old man who underwent talus reimplantation after isolated total talar extrusion.
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Affiliation(s)
- Bandar N AlMaeen
- Surgery/Orthopedic Surgery, College of Medicine, Jouf University, Al-Jouf, SAU
| | | | | | - Tareq A Alrefeidi
- Orthopedic Surgery, Armed Forces Hospital Southern Region, Khamis Mushyt, SAU
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Kang J, Zheng C, Park KW, Park J, Rhee T, Lee HS, Han JK, Yang HM, Kang HJ, Koo BK, Kim HS. Complete Revascularization of Multivessel Coronary Artery Disease Does Not Improve Clinical Outcome in ST-Segment Elevation Myocardial Infarction Patients with Reduced Left Ventricular Ejection Fraction. J Clin Med 2020; 9:jcm9010232. [PMID: 31952345 PMCID: PMC7019798 DOI: 10.3390/jcm9010232] [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] [Subscribe] [Scholar Register] [Received: 11/27/2019] [Revised: 01/07/2020] [Accepted: 01/08/2020] [Indexed: 01/26/2023] Open
Abstract
The benefit of complete revascularization (CR) in ST-segment elevation myocardial infarction (STEMI) patients with left ventricular (LV) dysfunction is uncertain. A total of 1314 STEMI patients with multivessel coronary artery disease were analyzed. CR was defined angiographically and by a residual Synergy between PCI with Taxus and Cardiac Surgery trial (SYNTAX) score (SS) <8. Patients with a left ventricular ejection fraction (LVEF) <40% were classified as the reduced LVEF group. The major study endpoints were patient-oriented composite outcome (POCO) and cardiac death during three-year follow-up. Overall, patients that received angiographic CR (579 patients, 44.1%) had significantly lower three-year clinical events compared with incomplete revascularization (iCR). CR reduced three-year POCO and cardiac death rates in the preserved LVEF group (POCO: 13.2% vs. 21.9%, p < 0.001, cardiac death: 1.8% vs. 6.5%, p < 0.001, respectively) but not in the reduced LVEF group (POCO: 26.0% vs. 33.1%, p = 0.275, cardiac death: 15.1% vs. 19.0%, p = 0.498, respectively). Multivariate analysis showed that CR significantly reduced three-year POCO (hazard ration (HR) 0.59, 95% confidence interval (CI) 0.43–0.82) and cardiac death (HR 0.34, 95% CI 0.14–0.80), only in the preserved LVEF group. Additionally, the results were corroborated using the SS-based CR definition. In STEMI patients with multivessel disease, CR did not improve clinical outcomes in those with reduced LVEF.
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Lee JM, Rhee TM, Kim HK, Hwang D, Lee SH, Choi KH, Kim J, Park TK, Yang JH, Song YB, Choi JH, Choi SH, Koo BK, Chae SC, Cho MC, Kim CJ, Kim JH, Kim HS, Gwon HC, Jeong MH, Hahn JY. Comparison of Long-Term Clinical Outcome Between Multivessel Percutaneous Coronary Intervention Versus Infarct-Related Artery-Only Revascularization for Patients With ST-Segment-Elevation Myocardial Infarction With Cardiogenic Shock. J Am Heart Assoc 2019; 8:e013870. [PMID: 31818215 PMCID: PMC6951086 DOI: 10.1161/jaha.119.013870] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [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: 11/16/2022]
Abstract
Background Data are limited regarding long‐term outcomes in patients with ST‐segment–elevation myocardial infarction and multivessel disease presenting with cardiogenic shock according to revascularization strategy. We sought to compare the 3‐year clinical outcomes of patients with ST‐segment‐elevation myocardial infarction multivessel disease with cardiogenic shock and patients with multivessel percutaneous coronary intervention (PCI) and infarct‐related artery (IRA)–only PCI. Methods and Results Of 13 104 patients from the nationwide, multicenter, prospective KAMIR‐NIH (Korea Acute Myocardial Infarction Registry––National Institutes of Health) registry, we selected 659 patients with ST‐segment‐elevation myocardial infarction who had concomitant non‐IRA stenosis and presented with cardiogenic shock. The primary outcome was all‐cause death. Multivessel PCI was performed in 260 patients and IRA‐only PCI in 399 patients. At 3 years, patients in the multivessel PCI group had a lower risk of all‐cause death (adjusted hazard ratio, 0.65; 95% CI, 0.45–0.94 [P=0.024]), all‐cause death or MI (adjusted hazard ratio, 0.59; 95% CI, 0.41–0.84 [P=0.004]), and non‐IRA repeat revascularization (adjusted hazard ratio, 0.23; 95% CI, 0.10–0.50 [P<0.001]) than those in the IRA‐only PCI group. The results were consistent after confounder adjustment by propensity score matching and inverse probability weighting analysis. Landmark analysis at 1 year demonstrated that the multivessel PCI group had a lower risk of recurrent MI and non‐IRA repeat revascularization beyond 1 year (log‐rank P=0.030 and P=0.017, respectively) than the IRA‐only PCI group. Conclusions In patients with ST‐segment‐elevation myocardial infarction and cardiogenic shock, multivessel PCI was associated with a lower risk of all‐cause death than IRA‐only PCI at 3 years, suggesting potential benefit of non‐IRA revascularization during the index hospitalization to improve long‐term clinical outcomes.
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Affiliation(s)
- Joo Myung Lee
- Division of Cardiology Department of Internal Medicine Heart Vascular Stroke Institute Samsung Medical Center Sungkyunkwan University School of Medicine Seoul Korea
| | - Tae-Min Rhee
- Department of Internal Medicine and Cardiovascular Center Seoul National University Hospital Seoul Korea
| | - Hyun Kuk Kim
- Department of Internal Medicine and Cardiovascular Center Chosun University Hospital University of Chosun College of Medicine Gwangju Korea
| | - Doyeon Hwang
- Department of Internal Medicine and Cardiovascular Center Seoul National University Hospital Seoul Korea
| | - Seung Hun Lee
- Division of Cardiology Department of Internal Medicine Heart Vascular Stroke Institute Samsung Medical Center Sungkyunkwan University School of Medicine Seoul Korea
| | - Ki Hong Choi
- Division of Cardiology Department of Internal Medicine Heart Vascular Stroke Institute Samsung Medical Center Sungkyunkwan University School of Medicine Seoul Korea
| | - Jihoon Kim
- Division of Cardiology Department of Internal Medicine Heart Vascular Stroke Institute Samsung Medical Center Sungkyunkwan University School of Medicine Seoul Korea
| | - Taek Kyu Park
- Division of Cardiology Department of Internal Medicine Heart Vascular Stroke Institute Samsung Medical Center Sungkyunkwan University School of Medicine Seoul Korea
| | - Jeong Hoon Yang
- Division of Cardiology Department of Internal Medicine Heart Vascular Stroke Institute Samsung Medical Center Sungkyunkwan University School of Medicine Seoul Korea
| | - Young Bin Song
- Division of Cardiology Department of Internal Medicine Heart Vascular Stroke Institute Samsung Medical Center Sungkyunkwan University School of Medicine Seoul Korea
| | - Jin-Ho Choi
- Division of Cardiology Department of Internal Medicine Heart Vascular Stroke Institute Samsung Medical Center Sungkyunkwan University School of Medicine Seoul Korea
| | - Seung-Hyuk Choi
- Division of Cardiology Department of Internal Medicine Heart Vascular Stroke Institute Samsung Medical Center Sungkyunkwan University School of Medicine Seoul Korea
| | - Bon-Kwon Koo
- Department of Internal Medicine and Cardiovascular Center Seoul National University Hospital Seoul Korea
| | - Shung Chull Chae
- Department of Internal Medicine Kyungpook National University Hospital Daegu Korea
| | - Myeong-Chan Cho
- Division of Cardiology Department of Internal Medicine Chungbuk National University Hospital Cheongju Korea
| | - Chong Jin Kim
- Department of Internal Medicine Kyunghee University College of Medicine Seoul Korea
| | - Ju Han Kim
- Department of Internal Medicine and Heart Center Chonnam National University Hospital Gwangju Korea
| | - Hyo-Soo Kim
- Department of Internal Medicine and Cardiovascular Center Seoul National University Hospital Seoul Korea
| | - Hyeon-Cheol Gwon
- Division of Cardiology Department of Internal Medicine Heart Vascular Stroke Institute Samsung Medical Center Sungkyunkwan University School of Medicine Seoul Korea
| | - Myung Ho Jeong
- Department of Internal Medicine and Heart Center Chonnam National University Hospital Gwangju Korea
| | - Joo-Yong Hahn
- Division of Cardiology Department of Internal Medicine Heart Vascular Stroke Institute Samsung Medical Center Sungkyunkwan University School of Medicine Seoul Korea
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Gershlick AH, Price MJ. Full Revascularization in the Patient With ST-Segment Elevation Myocardial Infarction: The Story So Far. J Am Coll Cardiol 2019; 74:2724-2727. [PMID: 31779787 DOI: 10.1016/j.jacc.2019.10.022] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [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: 10/21/2019] [Accepted: 10/22/2019] [Indexed: 01/17/2023]
Affiliation(s)
- Anthony H Gershlick
- Department of Cardiovascular Sciences, University Hospitals of Leicester, Leicester Biomedical Research Centre, University of Leicester, Leicester, United Kingdom.
| | - Matthew J Price
- Division of Cardiovascular Diseases, Scripps Clinic, La Jolla, California
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Mahmud E, Ben-Yehuda O. Percutaneous Coronary Intervention in Acute Coronary Syndrome: Completing the Job Saves Lives. J Am Coll Cardiol 2018; 72:2000-2. [PMID: 30336822 DOI: 10.1016/j.jacc.2018.08.2129] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2018] [Accepted: 08/14/2018] [Indexed: 11/23/2022]
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Li J, Yang X, Tian Y, Wei H, Hacker M, Li X, Zhang X. Complete revascularization determined by myocardial perfusion imaging could improve the outcomes of patients with stable coronary artery disease, compared with incomplete revascularization and no revascularization. J Nucl Cardiol 2019; 26:944-953. [PMID: 29214612 DOI: 10.1007/s12350-017-1145-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2017] [Accepted: 10/05/2017] [Indexed: 11/28/2022]
Abstract
OBJECTIVES To compare the outcomes among patients treated by complete coronary revascularization (CCR) or incomplete coronary revascularization (ICR) and no coronary revascularization (NCR) by myocardial perfusion imaging (MPI), as well as to evaluate the impact of severity of ischemia on patients with coronary artery disease (CAD) by different therapy strategies. BACKGROUND Using myocardial ischemia severity determined by MPI guiding treatment strategies for CAD patients still lacks strong clinical evidences. METHODS Consecutive patients (N = 286) underwent clinical stress-rest SPECT MPI and were retrospectively followed-up. For assessment of outcome of treatment, all patients were classified into three groups (CCR, ICR, and NCR), and further divided into two subgroups as mild ischemia (< 10% ischemic myocardium) and moderate-severe ischemia (≥ 10% ischemic myocardium). All-cause death was defined as the primary endpoint, and the composite of deaths, nonfatal myocardial infarction, and repeat revascularization (MACE) as the secondary endpoint. RESULTS Two-hundred eighty-six patients were followed-up for 46 ± 21 months. Thirty deaths and 65 MACEs were recorded. Patients treated by revascularization had significantly lower MACE (P < .001) but not mortality (P = .158) than patients treated by NCR. Outcomes of CCR related to mortality rate were greater than ICR and NCR (death: P = .019, MACE: P < .001). In patients with moderate-severe ischemia, CCR showed improved outcomes than ICR and NCR (death: P = .034; and MACE: P < .001). In patients with mild ischemia, the outcomes of CCR, ICR, and NCR had no significant difference (P > .05). Multivariate regression Cox analysis revealed that summed difference score [death: HR 1.09 (1.03, 1.15), P = .004] was an independent risk factor and CCR was an independent negative predictor [death: HR 0.31 (0.12, 0.81), P = .017; MACE: HR 0.30 (0.16, 0.57), P < .001]. CONCLUSIONS Outcomes of patients treated by CCR were most likely more promising in comparison with treatment of ICR and NCR, especially when patients had over 10% ischemic myocardium.
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Affiliation(s)
- Jiehui Li
- Department of Cardiac Surgery, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, and National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China.
| | - Xiubin Yang
- Department of Cardiac Surgery, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, and National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
| | - Yueqin Tian
- Department of Nuclear Medicine, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, and National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
| | - Hongxing Wei
- Department of Nuclear Medicine, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, and National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
| | - Marcus Hacker
- Department of Biomedical Imaging and Image-guided Therapy, Division of Nuclear Medicine, Medizinische Universitat Wien, Wien, Austria
| | - Xiang Li
- Department of Biomedical Imaging and Image-guided Therapy, Division of Nuclear Medicine, Medizinische Universitat Wien, Wien, Austria.
- Department of Nuclear Medicine, Beijing Anzhen Hospital, Capital Medical University, 100029, Beijing, People's Republic of China.
| | - Xiaoli Zhang
- Department of Nuclear Medicine, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, and National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China.
- Department of Nuclear Medicine, Beijing Anzhen Hospital, Capital Medical University, 100029, Beijing, People's Republic of China.
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Affiliation(s)
- Thomas F Whayne
- Gill Heart and Vascular Institute, University of Kentucky, Lexington, KY, USA
| | - Matthew J Sousa
- Gill Heart and Vascular Institute, University of Kentucky, Lexington, KY, USA
| | - Ahmed Abdel-Latif
- Gill Heart and Vascular Institute, University of Kentucky, Lexington, KY, USA
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Kyhl K, Ahtarovski KA, Nepper-Christensen L, Ekström K, Ghotbi AA, Schoos M, Göransson C, Bertelsen L, Helqvist S, Holmvang L, Jørgensen E, Pedersen F, Saunamäki K, Clemmensen P, De Backer O, Høfsten DE, Køber L, Kelbæk H, Vejlstrup N, Lønborg J, Engstrøm T. Complete Revascularization Versus Culprit Lesion Only in Patients With ST-Segment Elevation Myocardial Infarction and Multivessel Disease: A DANAMI-3-PRIMULTI Cardiac Magnetic Resonance Substudy. JACC Cardiovasc Interv 2019; 12:721-730. [PMID: 31000010 DOI: 10.1016/j.jcin.2019.01.248] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [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: 10/01/2018] [Revised: 01/25/2019] [Accepted: 01/29/2019] [Indexed: 10/27/2022]
Abstract
OBJECTIVES The aim of this study was to evaluate the effect of fractional flow reserve (FFR)-guided revascularization compared with culprit-only percutaneous coronary intervention (PCI) in patients with ST-segment elevation myocardial infarction (STEMI) on infarct size, left ventricular (LV), function, LV remodeling, and the presence of nonculprit infarctions. BACKGROUND Patients with STEMI with multivessel disease might have improved clinical outcomes after complete revascularization compared with PCI of the infarct-related artery only, but the impact on infarct size, LV function, and remodeling as well as the risk for periprocedural infarction are unknown. METHODS In this substudy of the DANAMI-3 (Third Danish Trial in Acute Myocardial Infarction)-PRIMULTI (Primary PCI in Patients With ST-Elevation Myocardial Infarction and Multivessel Disease: Treatment of Culprit Lesion Only or Complete Revascularization) randomized trial, patients with STEMI with multivessel disease were randomized to receive either complete FFR-guided revascularization or PCI of the culprit vessel only. The patients underwent cardiac magnetic resonance imaging during index admission and at 3-month follow-up. RESULTS A total of 280 patients (136 patients with infarct-related and 144 with complete FFR-guided revascularization) were included. There were no differences in final infarct size (median 12% [interquartile range: 5% to 19%] vs. 11% [interquartile range: 4% to 18%]; p = 0.62), myocardial salvage index (median 0.71 [interquartile range: 0.54 to 0.89] vs. 0.66 [interquartile range: 0.55 to 0.87]; p = 0.49), LV ejection fraction (mean 58 ± 9% vs. 59 ± 9%; p = 0.39), and LV end-systolic volume remodeling (mean 7 ± 22 ml vs. 7 ± 19 ml; p = 0.63). New nonculprit infarction occurring after the nonculprit intervention was numerically more frequent among patients treated with complete revascularization (6 [4.5%] vs. 1 [0.8%]; p = 0.12). CONCLUSIONS Complete FFR-guided revascularization in patients with STEMI and multivessel disease did not affect final infarct size, LV function, or remodeling compared with culprit-only PCI.
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Affiliation(s)
- Kasper Kyhl
- Department of Cardiology, Rigshospitalet, Copenhagen, Denmark.
| | | | | | | | - Adam Ali Ghotbi
- Department of Cardiology, Rigshospitalet, Copenhagen, Denmark
| | - Mikkel Schoos
- Department of Cardiology, Rigshospitalet, Copenhagen, Denmark
| | | | | | | | - Lene Holmvang
- Department of Cardiology, Rigshospitalet, Copenhagen, Denmark
| | - Erik Jørgensen
- Department of Cardiology, Rigshospitalet, Copenhagen, Denmark
| | - Frants Pedersen
- Department of Cardiology, Rigshospitalet, Copenhagen, Denmark
| | - Kari Saunamäki
- Department of Cardiology, Rigshospitalet, Copenhagen, Denmark
| | - Peter Clemmensen
- Department of Medicine, Nykoebing F Hospital, Nykoebing F and University of Southern Denmark, Odense, Denmark; University Clinic of Hamburg-Eppendorf, The Heart Centre, Hamburg, Germany
| | - Ole De Backer
- Department of Cardiology, Rigshospitalet, Copenhagen, Denmark
| | - Dan Eik Høfsten
- Department of Cardiology, Rigshospitalet, Copenhagen, Denmark
| | - Lars Køber
- Department of Cardiology, Rigshospitalet, Copenhagen, Denmark
| | - Henning Kelbæk
- Department of Cardiology, Zealand University, Roskilde, Denmark
| | - Niels Vejlstrup
- Department of Cardiology, Zealand University, Roskilde, Denmark
| | - Jacob Lønborg
- Department of Cardiology, Zealand University, Roskilde, Denmark
| | - Thomas Engstrøm
- Department of Cardiology, Rigshospitalet, Copenhagen, Denmark; Department of Cardiology, University of Lund, Lund, Sweden
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Abstract
Percutaneous coronary intervention (PCI) of chronic coronary total occlusion is the latest frontier in percutaneous intervention. There are vast improvements in the initial success and safety of the procedure as well as a better understanding of appropriateness and benefits. Advances in technology and skill allow for increased utilization of PCI in cases of chronic coronary total occlusion, with benefits regarding symptoms and quality of life. Percutaneous coronary intervention for chronic coronary total occlusion can correct ischemia and achieve complete revascularization while avoiding traditional coronary bypass grafting, although survival benefits remain unclear.
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Affiliation(s)
- Alpesh Shah
- HOUSTON METHODIST DEBAKEY HEART & VASCULAR CENTER, HOUSTON METHODIST HOSPITAL, HOUSTON, TEXAS
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50
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Kim J, Lee JM, Choi KH, Rhee TM, Hwang D, Park J, Ahn C, Park TK, Yang JH, Song YB, Choi JH, Hahn JY, Choi SH, Gwon HC. Differential Clinical Outcomes Between Angiographic Complete Versus Incomplete Coronary Revascularization, According to the Presence of Chronic Kidney Disease in the Drug-Eluting Stent Era. J Am Heart Assoc 2018; 7:JAHA.117.007962. [PMID: 29449272 PMCID: PMC5850202 DOI: 10.1161/jaha.117.007962] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [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: 11/16/2022]
Abstract
BACKGROUND There are limited data regarding the prognostic impact of angiographic complete revascularization (CR) in patients with chronic kidney disease (CKD). We sought to investigate the differential prognostic impact of angiographic CR over incomplete revascularization (IR), according to the presence of CKD in the drug-eluting stent era. METHODS AND RESULTS Between 2003 and 2011 at Samsung Medical Center, consecutive patients with multivessel disease were stratified by the presence of CKD (estimated glomerular filtration rate <60 mL/min per 1.73 m2) and classified according to angiographic CR (residual SYNTAX score=0) or IR. Clinical outcomes were compared between angiographic CR and IR, stratified by the presence of CKD. Primary outcome was patient-oriented composite outcomes (POCO, a composite of all-cause death, myocardial infarction, any revascularization) at 3 years. Inverse probability weighting was performed between the CR and IR groups. A total of 3224 patients were eligible for analysis: 2295 without CKD; 929 with CKD. Among non-CKD patients, angiographic CR showed a significantly lower risk of POCO than IR (17.2% versus 21.7%, adjusted hazard ratio 0.76, 95% confidence interval, 0.62-0.95, P=0.014), mainly driven by a significantly lower risk of any revascularization. Among CKD patients, however, angiographic CR was associated with a significantly higher risk of POCO than IR (37.7% versus 28.4%, adjusted hazard ratio 1.42, 95% confidence interval, 1.08%-1.85%, P=0.011), mainly driven by a significantly higher risk of nonfatal target vessel myocardial infarction. CONCLUSIONS Angiographic CR was associated with reduced risk of POCO than IR in patients without CKD; however, it was associated with a significantly higher risk of POCO and nonfatal myocardial infarction in CKD patients.
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Affiliation(s)
- Jihoon Kim
- Department of Internal Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Joo Myung Lee
- Department of Internal Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Ki Hong Choi
- Department of Internal Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Tae-Min Rhee
- National Maritime Medical Center, Changwon, Korea
| | - Doyeon Hwang
- Department of Internal Medicine and Cardiovascular Center, Seoul National University Hospital, Seoul, Korea
| | - Jonghanne Park
- Department of Internal Medicine, Naju National Hospital, Ministry of Health and Welfare, Naju, Korea
| | - Chul Ahn
- Division of Biostatistics, Center for Devices and Radiological Health, Food and Drug Administration, Silver Spring, MD
| | - Taek Kyu Park
- Department of Internal Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jeong Hoon Yang
- Department of Internal Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Young Bin Song
- Department of Internal Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jin-Ho Choi
- Department of Internal Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Joo-Yong Hahn
- Department of Internal Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Seung-Hyuk Choi
- Department of Internal Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Hyeon-Cheol Gwon
- Department of Internal Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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