Diagnosis of silent coronary ischemia with selective coronary revascularization might improve 2-year survival of patients with critical limb-threatening ischemia

BACKGROUND

Patients with critical limb-threatening ischemia (CLTI) have had poor long-term survival after lower extremity revascularization owing to coexistent coronary artery disease. A new cardiac diagnostic test, coronary computed tomography-derived fractional flow reserve (FFR_CT), can identify patients with ischemia-producing coronary stenosis who might benefit from coronary revascularization. We sought to determine whether the diagnosis of silent coronary ischemia before limb salvage surgery with selective postoperative coronary revascularization can reduce the incidence of adverse cardiac events and improve the survival of patients with CLTI compared with standard care.

METHODS

Patients with CLTI and no cardiac history or symptoms who had undergone preoperative testing to detect silent coronary ischemia with selective postoperative coronary revascularization (group I) were compared with patients with standard preoperative cardiac clearance and no elective postoperative coronary revascularization (group II). Both groups received guideline-directed medical care. Lesion-specific coronary ischemia in group I was defined as FFR_CT of ≤0.80 distal to a stenosis, with severe ischemia defined as FFR_CT of ≤0.75. The endpoints included all-cause death, cardiovascular (CV) death, myocardial infarction (MI), major adverse CV events (i.MACE; CV death, MI, unplanned coronary revascularization, stroke) through 2 years of follow-up.

RESULTS

Groups I (n = 111) and II (n = 120) were similar in age (66 ± 9 vs 66 ± 7 years), gender (78% vs 83% men), comorbidities, and surgery performed. In group I, unsuspected, silent coronary ischemia was found in 71 of 103 patients (69%), with severe ischemia in 58% and left main coronary ischemia in 8%. Elective postoperative coronary revascularization was performed in 47 of 71 patients with silent ischemia (66%). In group II, the status of silent coronary ischemia was unknown. The median follow-up was >2 years for both groups. The 2-year outcomes for groups I and II were as follows: all-cause death, 8.1% and 20.0% (hazard ratio [HR], 0.38; 95% confidence interval [CI], 0.18-0.84; P = .016); CV death, 4.5% and 13.3% (HR, 0.32; 95% CI, 0.11-0.88; P = .028); MI, 6.3% and 17.5% (HR, 0.33; 95% CI, 0.14-0.79; P = .012); and major adverse CV events, 10.8% and 23.3% (HR, 0.44; 95% CI, 0.22-0.88; P = .021), respectively.

CONCLUSIONS

The preoperative evaluation of patients with CLTI and no known coronary artery disease using coronary FFR_CT revealed silent coronary ischemia in two of every three patients. Selective coronary revascularization of patients with silent coronary ischemia after recovery from limb salvage surgery resulted in fewer CV deaths and MIs and improved 2-year survival compared with patients with CLTI who had received standard cardiac evaluation and care. Prospective controlled studies are required to further define the role of FFR_CT in the evaluation and treatment of patients with CLTI.

Clinical profiles and outcomes in the treatment of acute myocardial infarction in Japan of aging society

To address many uncertainties in the acute care of patients with acute myocardial infarction (AMI) in proportion to increasing age, we underwent the nationwide current survey consisted of 11,676 patients with AMI based on the database of the Japanese Acute Myocardial Infarction Registry between January 2011 and December 2013 to figure out how difference of clinical profiles and outcomes between coronary revascularization and conservative treatments for AMI. Clinical profiles in a total of 763 patients with AMI with conservative treatments (7% of all) were characterized as more elderly women (median age, 71 yeas vs. 68 years, p < 0.0001, male, 71% vs. 76%, p = 0.0008), high Killip class (Killip class I, 61% vs. 75%, p < 0.0001), and non-ST-segment elevation AMI (37% vs. 27%, p < 0.0001) as compared with 10,913 with coronary revascularization, with a consequence of more than twofold higher in-hospital mortality (12% vs. 5%, p < 0.0001). When compared with conservative treatments, highly effective of coronary revascularization to decrease in-hospital mortality was found in patients with ST-segment elevation AMI (6% vs. 16%, p < 0.0001), while these advantages were not evident in those with non-ST-segment elevation AMI (4% vs. 6%, p = 0.1107), especially with high Killip class, regardless of whether or not propensity score matching of clinical characteristics. A risk-adapted allocation of invasive management therefore may have the potential of benefiting patients with non-ST-segment elevation AMI, in particular elders.

Statistics on mortality following acute myocardial infarction in 842 897 Europeans

AIMS

To compare ST-segment elevation myocardial infarction (STEMI) and non-STEMI (NSTEMI) mortality between Sweden and the UK, adjusting for background population rates of expected death, case mix, and treatments.

METHODS AND RESULTS

National data were collected from hospitals in Sweden [n = 73 hospitals, 180 368 patients, Swedish Web-system for Enhancement and Development of Evidence-based care in Heart disease Evaluated According to Recommended Therapies (SWEDEHEART)] and the UK [n = 247, 662 529 patients, Myocardial Ischaemia National Audit Project (MINAP)] between 2003 and 2013. There were lower rates of revascularization [STEMI (43.8% vs. 74.9%); NSTEMI (27.5% vs. 43.6%)] and pharmacotherapies at time of hospital discharge including [aspirin (82.9% vs. 90.2%) and (79.9% vs. 88.0%), β-blockers (73.4% vs. 86.4%) and (65.3% vs. 85.1%)] in the UK compared with Sweden, respectively. Standardized net probability of death (NPD) between admission and 1 month was higher in the UK for STEMI [8.0 (95% confidence interval 7.4-8.5) vs. 6.7 (6.5-6.9)] and NSTEMI [6.8 (6.4-7.2) vs. 4.9 (4.7-5.0)]. Between 6 months and 1 year and more than 1 year, NPD remained higher in the UK for NSTEMI [2.9 (2.5-3.3) vs. 2.3 (2.2-2.5)] and [21.4 (20.0-22.8) vs. 18.3 (17.6-19.0)], but was similar for STEMI [0.7 (0.4-1.0) vs. 0.9 (0.7-1.0)] and [8.4 (6.7-10.1) vs. 8.3 (7.5-9.1)].

CONCLUSION

Short-term mortality following STEMI and NSTEMI was higher in the UK compared with Sweden. Mid- and longer-term mortality remained higher in the UK for NSTEMI but was similar for STEMI. Differences in mortality may be due to differential use of guideline-indicated treatments.

Extent of Myocardial Ischemia on Positron Emission Tomography and Survival Benefit With Early Revascularization

BACKGROUND

Prior studies with single-photon emission computed tomography (SPECT) myocardial perfusion imaging (MPI) have shown a survival benefit with early revascularization in patients with >10% to 12.5% ischemic myocardium. The relationship among positron emission tomography (PET)-derived extent of ischemia, early revascularization, and survival is unknown.

OBJECTIVES

The purpose of this study was to evaluate the association among percent ischemia on PET MPI, revascularization, and survival.

METHODS

A total of 16,029 unique consecutive patients who were undergoing Rubidium-82 rest-stress PET MPI from 2010 to 2016 were included. Patients with known cardiomyopathy and nondiagnostic perfusion results were excluded. Percent ischemic myocardium was estimated from a 17-segment model. Propensity scoring was used to account for nonrandomized referral to early revascularization (90 days of PET). A Cox model was developed, adjusting for propensity scores for early revascularization and percent ischemia, and an interaction between ischemia and early revascularization was tested.

RESULTS

Median follow-up was 3.7 years. Overall, 1,277 (8%) patients underwent early revascularization and 2,493 (15.6%) died (738 cardiac). Nearly 37% of patients (n = 5,902) had ischemia, with 13.5% (n = 2,160) having ≥10%. In propensity-adjusted analyses, there was a significant interaction between ischemia and early revascularization (p < 0.001 for all-cause and cardiac death), such that patients with greater ischemia had improved survival with early revascularization, with a potential ischemia threshold at 5% (upper limit 95% confidence interval at 10%). There was no differential association between ischemia and early revascularization on death based on history of known coronary artery disease (interaction p = 0.72).

CONCLUSIONS

In a contemporary cohort of patients undergoing PET MPI, patients with greater ischemia had a survival benefit from early revascularization. On exploratory analyses, this threshold was lower than that previously reported for SPECT. These findings require future validation in prospective cohorts or trials.

Deferral Versus Performance of Revascularization for Coronary Stenosis With Grey Zone Fractional Flow Reserve Values: A Systematic Review and Meta-Analysis

We searched PubMed, EMBASE, Cochrane Library, and Web of Science for studies using fractional flow reserve (FFR) to determine whether revascularization should be performed or deferred for patients with coronary stenosis and grey zone FFR. Meta-analysis was performed using the generic inverse variance method, and hazard ratios (HR) were synthesized with a random-effects model. Of 2766 records, 7 nonrandomized studies including 2683 patients were selected. The pooled results demonstrated, during a median follow-up of 32 months, that revascularization significantly reduced the risk of major adverse cardiac events (MACE; 7 studies: HR [95% confidence interval, CI]: 0.65 [0.45-0.93], P = .02) and target vessel revascularization (TVR; 4 studies: HR [95% CI]: 0.52 [0.36-0.76], P < .01). Whereas revascularization was not significantly superior in terms of all-cause death (3 studies: HR [95% CI]: 0.56 [0.26-1.22], P = .14), cardiac death (2 studies: HR [95% CI]: 0.57 [0.16-2.01], P = .38), myocardial infarction (MI; 4 studies: HR [95% CI]: 1.03 [0.26-4.03]), and all-cause death or MI (3 studies: HR [95% CI]: 0.66 [0.20-2.19], P = .50). Therefore, revascularization appeared to be superior to deferral for patients with grey zone FFR in MACE and TVR, while hard end points did not show such significance. This work was registered in PROSPERO (CRD42019118432).

[Polymorbidity in elderly patients needing myocardial revascularization (a review article).]

In the present review, the main attention is focused on the problem of polymorbidity and age-related conditions in elderly patients with CAD who need myocardial revascularization. In addition to a high risk of mortality, elderly patients with polymorbidity are characterized reduced functional activity, cognitive impairment, low quality of life and frequent seeking medical help. There is evidence of the presence of common mechanisms that affect the aging process and the development of a number of associated diseases associated with age. Accordingly, the study of polymorbidity will allow us to develop strategies for the prevention it and understand the aging process and significantly reduce the risks of surgical intervention. In this regard, there is a necessity for research aimed at studying the causal relationship between coronary artery disease and polymorbidity in elderly patients with an additional assessment of functional and cognitive status for the development of specific prognostic tools and treatment strategies.

Do We Need Potent Intravenous Antiplatelet Inhibition at the Time of Reperfusion During ST-Segment Elevation Myocardial Infarction?

Acute myocardial infarction (MI) is still a large source of morbidity and mortality worldwide. Although early reperfusion therapy has been prioritized in the modern era of percutaneous coronary intervention and thrombolysis, attempts at incremental improvements in clinical outcomes by reducing MI size have not been successful so far. Herein, we review the studies that have evaluated immediate-onset antiplatelet therapy as attempts to improve meaningful clinical outcomes in ST-segment elevation MI (STEMI). Unfortunately, many of the adjunctive pharmacotherapies have proven to be disappointing. Recent studies performed in the background of routine oral administration of P2Y₁₂ adenosine receptor inhibitors, which may take several hours to take full effect, and aspirin have largely shown no improvement in outcomes, despite an earlier onset of antiplatelet activity of the investigative agents. Further progress in improving outcomes during STEMI may depend on exploring therapeutics that modulate the pathophysiology of microvascular damage during ischemia-reperfusion injury, a phenomenon whose effects evolve over hours to days. We speculate that the dynamic nature of the no-reflow phenomenon may be an explanation for these disappointing results with the intravenous antiplatelet agents. We hope that appreciation for what has not worked in this domain may direct future research efforts to focus on novel pathways. Myocardial ischemia and reperfusion injury are very much still a lingering issue. Despite significant improvements in door-to-balloon times, rates of in-hospital mortality for STEMI remain unchanged. Outcomes following successfully reperfused STEMI are likely determined by the initial size of myocardial necrosis (ie, cardiomyocyte death during the period of ongoing ischemia), patency of the infarct-related epicardial coronary artery, possible reperfusion injury, the microvascular no-reflow phenomenon, and adverse remodeling after infarction.

Effect of atrial fibrillation in Asian patients undergoing percutaneous coronary intervention with drug-eluting stents for stable coronary artery disease: Results from a Korean nationwide study

Although the prevalence of atrial fibrillation (AF) and percutaneous coronary intervention (PCI) are increasing in Asia, there is a paucity of data concerning the effect of AF in Asian patients undergoing PCI with drug-eluting stents (DESs). Furthermore, the majority of previous studies investigating the effect of AF on prognosis following PCI have exclusively evaluated patients with myocardial infarction (MI). We aimed to evaluate the effect of AF on clinical outcomes of Asian patients undergoing PCI with DES for coronary artery disease (CAD) excluding acute MI.From national health insurance claims data in South Korea, a total of 45,288 patients aged 18 years or older without a known history of CAD, who underwent PCI with DES for the diagnosis of CAD excluding acute MI between 2011 and 2015, were enrolled. Based on the presence or absence of a history of AF at baseline, patients were categorized into the AF group (n = 1715, 3.8%) and no-AF group (n = 43,573, 96.2%). Outcomes including all-cause death, the composite outcome of all-cause death/MI/coronary revascularization, and stroke were compared between 2 groups using a propensity-score-matched analysis.After propensity-score matching, 1709 matched pairs were obtained. During the follow-up period (mean, 2.2 years), the incidence of all-cause death (hazard ratio [HR] 1.117, 95% confidence interval [CI] 0.885-1.411, P = .35) and the composite outcome of all-cause death/MI/coronary revascularization (HR 1.004, 95% CI 0.846-1.192, P = .97) were not significantly different between 2 groups. However, the incidence of stroke was significantly increased in the AF group (HR 1.983, 95% CI 1.474-2.667, P < .001).In Asian patients undergoing PCI for stable CAD, a history of AF was not associated with mortality, but was associated with increased risk of stroke.

High-sensitivity C-reactive protein, low-density lipoprotein cholesterol and cardiovascular outcomes in patients with type 2 diabetes in the EXAMINE (Examination of Cardiovascular Outcomes with Alogliptin versus Standard of Care) trial

AIMS

We sought to assess the risk of major adverse cardiovascular events (MACE) by utilizing high-sensitivity C-reactive protein (hsCRP) level and low-density lipoprotein cholesterol (LDL-C) in patients with type 2 diabetes and recent acute coronary syndrome.

MATERIALS AND METHODS

Study participants enrolled in the EXAMINE trial (Clinical trials registration number: NCT00968708) and were stratified by baseline hsCRP levels (<1, 1-3 and >3 mg/L). They were also sub-divided into 4 groups according to baseline hsCRP (≤3 or >3 mg/L) and achieved LDL-C (<70 or ≥70 mg/dL) levels. Among 5380 patients, the MACE rate, a composite of cardiovascular death, non-fatal acute myocardial infarction and non-fatal stroke, was evaluated during the 30 months of follow-up.

RESULTS

Cumulative incidence of MACE was 11.5% (119 events), 14.6% (209 events) and 18.4% (287 events) in patients with hsCRP levels of <1, 1 to 3 and >3 mg/L, respectively (P < .001). In patients with hsCRP >3 mg/L, the adjusted hazard ratio (95% confidence interval) was 1.42 (1.13, 1.78; P = .002) for MACE compared with patients with hsCRP <1 mg/L. MACE cumulative incidences were 11.0% (128 events), 14.4% (100 events), 15.6% (194 events) and 21.3% (182 events) in patients with low LDL-C and low hsCRP, low LDL-C and high hsCRP, high LDL-C and low hsCRP, and high LDL-C and high hsCRP levels, respectively (P < .001).

CONCLUSIONS

Levels of hsCRP were associated with recurrent cardiovascular events in patients with type 2 diabetes and recent acute coronary syndrome, and this association appears to be independent of and additive to the achieved LDL-C level.

Home-based versus centre-based cardiac rehabilitation

BACKGROUND

Cardiovascular disease is the most common cause of death globally. Traditionally, centre-based cardiac rehabilitation programmes are offered to individuals after cardiac events to aid recovery and prevent further cardiac illness. Home-based cardiac rehabilitation programmes have been introduced in an attempt to widen access and participation. This is an update of a review previously published in 2009 and 2015.

OBJECTIVES

To compare the effect of home-based and supervised centre-based cardiac rehabilitation on mortality and morbidity, exercise-capacity, health-related quality of life, and modifiable cardiac risk factors in patients with heart disease.

SEARCH METHODS

We updated searches from the previous Cochrane Review by searching the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE (Ovid), Embase (Ovid), PsycINFO (Ovid) and CINAHL (EBSCO) on 21 September 2016. We also searched two clinical trials registers as well as previous systematic reviews and reference lists of included studies. No language restrictions were applied.

SELECTION CRITERIA

We included randomised controlled trials, including parallel group, cross-over or quasi-randomised designs) that compared centre-based cardiac rehabilitation (e.g. hospital, gymnasium, sports centre) with home-based programmes in adults with myocardial infarction, angina, heart failure or who had undergone revascularisation.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened all identified references for inclusion based on pre-defined inclusion criteria. Disagreements were resolved through discussion or by involving a third review author. Two authors independently extracted outcome data and study characteristics and assessed risk of bias. Quality of evidence was assessed using GRADE principles and a Summary of findings table was created.

MAIN RESULTS

We included six new studies (624 participants) for this update, which now includes a total of 23 trials that randomised a total of 2890 participants undergoing cardiac rehabilitation. Participants had an acute myocardial infarction, revascularisation or heart failure. A number of studies provided insufficient detail to enable assessment of potential risk of bias, in particular, details of generation and concealment of random allocation sequencing and blinding of outcome assessment were poorly reported.No evidence of a difference was seen between home- and centre-based cardiac rehabilitation in clinical primary outcomes up to 12 months of follow up: total mortality (relative risk (RR) = 1.19, 95% CI 0.65 to 2.16; participants = 1505; studies = 11/comparisons = 13; very low quality evidence), exercise capacity (standardised mean difference (SMD) = -0.13, 95% CI -0.28 to 0.02; participants = 2255; studies = 22/comparisons = 26; low quality evidence), or health-related quality of life up to 24 months (not estimable). Trials were generally of short duration, with only three studies reporting outcomes beyond 12 months (exercise capacity: SMD 0.11, 95% CI -0.01 to 0.23; participants = 1074; studies = 3; moderate quality evidence). However, there was evidence of marginally higher levels of programme completion (RR 1.04, 95% CI 1.00 to 1.08; participants = 2615; studies = 22/comparisons = 26; low quality evidence) by home-based participants.

AUTHORS' CONCLUSIONS

This update supports previous conclusions that home- and centre-based forms of cardiac rehabilitation seem to be similarly effective in improving clinical and health-related quality of life outcomes in patients after myocardial infarction or revascularisation, or with heart failure. This finding supports the continued expansion of evidence-based, home-based cardiac rehabilitation programmes. The choice of participating in a more traditional and supervised centre-based programme or a home-based programme may reflect local availability and consider the preference of the individual patient. Further data are needed to determine whether the effects of home- and centre-based cardiac rehabilitation reported in the included short-term trials can be confirmed in the longer term and need to consider adequately powered non-inferiority or equivalence study designs.

Complete versus culprit-only revascularisation in ST elevation myocardial infarction with multi-vessel disease

BACKGROUND

Multi-vessel coronary disease in people with ST elevation myocardial infarction (STEMI) is common and is associated with worse prognosis after STEMI. Based on limited evidence, international guidelines recommend intervention on only the culprit vessel during STEMI. This, in turn, leaves other significantly stenosed coronary arteries for medical therapy or revascularisation based on inducible ischaemia on provocative testing. Newer data suggest that intervention on both the culprit and non-culprit stenotic coronary arteries (complete intervention) may yield better results compared with culprit-only intervention.

OBJECTIVES

To assess the effects of early complete revascularisation compared with culprit vessel only intervention strategy in people with STEMI and multi-vessel coronary disease.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials, MEDLINE, Embase, World Health Organization International Clinical Trials Registry Platform Search Portal, and ClinicalTrials.gov. The date of the last search was 4 January 2017. We applied no language restrictions. We handsearched conference proceedings to December 2016, and contacted authors and companies related to the field.

SELECTION CRITERIA

We included only randomised controlled trials (RCTs), wherein complete revascularisation strategy was compared with a culprit-only percutaneous coronary intervention (PCI) for the treatment of people with STEMI and multi-vessel coronary disease.

DATA COLLECTION AND ANALYSIS

We assessed the methodological quality of each trial using the Cochrane 'Risk of bias' tool. We resolved the disagreements by discussion among review authors. We followed standard methodological approaches recommended by Cochrane. The primary outcomes were long-term (one year or greater after the index intervention) all-cause mortality, long-term cardiovascular mortality, long-term non-fatal myocardial infarction, and adverse events. The secondary outcomes were short-term (within the first 30 days after the index intervention) all-cause mortality, short-term cardiovascular mortality, short-term non-fatal myocardial infarction, revascularisation, health-related quality of life, and cost. We analysed data using fixed-effect models, and expressed results as risk ratios (RR) with 95% confidence intervals (CI). We used GRADE criteria to assess the quality of evidence and we conducted Trial Sequential Analysis (TSA) to control risks of random errors.

MAIN RESULTS

We included nine RCTs, that involved 2633 people with STEMI and multi-vessel coronary disease randomly assigned to either a complete (n = 1381) versus culprit-only (n = 1252) revascularisation strategy. The complete and the culprit-only revascularisation strategies did not differ for long-term all-cause mortality (65/1274 (5.1%) in complete group versus 72/1143 (6.3%) in culprit-only group; RR 0.80, 95% CI 0.58 to 1.11; participants = 2417; studies = 8; I2 = 0%; very low quality evidence). Compared with culprit-only intervention, the complete revascularisation strategy was associated with a lower proportion of long-term cardiovascular mortality (28/1143 (2.4%) in complete group versus 51/1086 (4.7%) in culprit-only group; RR 0.50, 95% CI 0.32 to 0.79; participants = 2229; studies = 6; I2 = 0%; very low quality evidence) and long-term non-fatal myocardial infarction (47/1095 (4.3%) in complete group versus 70/1004 (7.0%) in culprit-only group; RR 0.62, 95% CI 0.44 to 0.89; participants = 2099; studies = 6; I2 = 0%; very low quality evidence). The complete and the culprit-only revascularisation strategies did not differ in combined adverse events (51/2096 (2.4%) in complete group versus 57/1990 (2.9%) in culprit-only group; RR 0.84, 95% CI 0.58 to 1.21; participants = 4086; I2 = 0%; very low quality evidence). Complete revascularisation was associated with lower proportion of long-term revascularisation (145/1374 (10.6%) in complete group versus 258/1242 (20.8%) in culprit-only group; RR 0.47, 95% CI 0.39 to 0.57; participants = 2616; studies = 9; I2 = 31%; very low quality evidence). TSA of long-term all-cause mortality, long-term cardiovascular mortality, and long-term non-fatal myocardial infarction showed that more RCTs are needed to reach more conclusive results on these outcomes. Regarding long-term repeat revascularisation more RCTs may not change our present result. The quality of the evidence was judged to be very low for all primary and the majority of the secondary outcomes mainly due to risk of bias, imprecision, and indirectness.

AUTHORS' CONCLUSIONS

Compared with culprit-only intervention, the complete revascularisation strategy may be superior due to lower proportions of long-term cardiovascular mortality, long-term revascularisation, and long-term non-fatal myocardial infarction, but these findings are based on evidence of very low quality. TSA also supports the need for more RCTs in order to draw stronger conclusions regarding the effects of complete revascularisation on long-term all-cause mortality, long-term cardiovascular mortality, and long-term non-fatal myocardial infarction.

Analysis of the Use of Extracorporeal Circulation on the In-Hospital Outcomes of Dialytic Patients Who Underwent Myocardial Revascularization Surgery

BACKGROUND

Myocardial revascularization surgery is the best treatment for dyalitic patients with multivessel coronary disease. However, the procedure still has high morbidity and mortality. The use of extracorporeal circulation (ECC) can have a negative impact on the in-hospital outcomes of these patients.

OBJECTIVES

To evaluate the differences between the techniques with ECC and without ECC during the in-hospital course of dialytic patients who underwent surgical myocardial revascularization.

METHODS

Unicentric study on 102 consecutive, unselected dialytic patients, who underwent myocardial revascularization surgery in a tertiary university hospital from 2007 to 2014.

RESULTS

Sixty-three patients underwent surgery with ECC and 39 without ECC. A high prevalence of cardiovascular risk factors was found in both groups, without statistically significant difference between them. The group "without ECC" had greater number of revascularizations (2.4 vs. 1.7; p <0.0001) and increased need for blood components (77.7% vs. 25.6%; p <0.0001) and inotropic support (82.5% vs 35.8%; p <0.0001). In the postoperative course, the group "without ECC" required less vasoactive drugs, (61.5% vs. 82.5%; p = 0.0340) and shorter time of mechanical ventilation (13.0 hours vs. 36,3 hours, p = 0.0217), had higher extubation rates in the operating room (58.9% vs. 23.8%, p = 0.0006), lower infection rates (7.6% vs. 28.5%; p = 0.0120), and shorter ICU stay (5.2 days vs. 8.1 days; p = 0.0054) as compared with the group with ECC surgery. No difference in mortality was found between the groups.

CONCLUSION

Myocardial revascularization with ECC in patients on dialysis resulted in higher morbidity in the perioperative period in comparison with the procedure without ECC, with no difference in mortality though.

Optimal Treatment Strategies in Patients with Chronic Kidney Disease and Coronary Artery Disease

BACKGROUND

Chronic kidney disease is an independent risk factor for coronary artery disease and is associated with an increase in adverse outcomes. However, the optimal treatment strategies for patients with chronic kidney disease and coronary artery disease are yet to be defined.

METHODS

MEDLINE, EMBASE, and CENTRAL were searched for studies including at least 100 patients with chronic kidney disease (defined as estimated glomerular filtration rate ≤60 mL/min/1.73 m² or on dialysis) and coronary artery disease treated with medical therapy, percutaneous coronary intervention, or coronary artery bypass surgery and followed for at least 1 month and reporting outcomes. The outcome evaluated was all-cause mortality. Meta-analysis was performed to evaluate the outcomes with revascularization (percutaneous coronary intervention or coronary artery bypass surgery) when compared with medical therapy alone. In addition, outcomes with percutaneous coronary intervention vs coronary artery bypass surgery were evaluated.

RESULTS

The search yielded 38 nonrandomized studies that enrolled 85,731 patients. Revascularization (percutaneous coronary intervention or coronary artery bypass surgery) was associated with lower long-term mortality (mean 4.0 years) when compared with medical therapy alone (relative risk [RR] 0.73; 95% confidence interval [CI], 0.62-0.87), driven by lower mortality with percutaneous coronary intervention vs medical therapy and coronary artery bypass surgery vs medical therapy. Coronary artery bypass surgery was associated with a higher upfront risk of death (RR 1.81; 95% CI, 1.47-2.24) but a lower long-term risk of death (RR 0.94; 95% CI, 0.89-0.98) when compared with percutaneous coronary intervention.

CONCLUSIONS

In chronic kidney disease patients with coronary artery disease, the current data from nonrandomized studies indicate lower mortality with revascularization, via either coronary artery bypass surgery or percutaneous coronary intervention, when compared with medical therapy. These associations should be tested in future randomized trials.

Transmyocardial Revascularization: Peril and Potential

Transmyocardial laser revascularization is a technique for the treatment of patients with chronic angina pectoris that is refractory to medical therapy and who are not eligible for surgical intervention. Percutaneous myocardial revascularization is a less-invasive catheter-based procedure that has been adapted from transmyocardial laser revascularization. Six prospective randomized clinical trials have been performed with transmyocardial laser revascularization and 5 have been performed using percutaneous myocardial revascularization. All of the transmyocardial laser revascularization and 4 of the percutaneous myocardial revascularization studies showed a significant improvement in angina class; however, results for improved survival, increased exercise tolerance, improved ejection fraction, and improved myocardial perfusion were less definitive. Transmyocardial laser revascularization has significant potential for morbidity and mortality. This article summarizes the results of the randomized trials, explains the current theories for the mechanism of transmyocardial laser revascularization, and discusses its current role in treatment for patients, considering the evidence that currently exists.

Impact of incomplete revascularization of coronary artery disease on long-term cardiac outcomes. Retrospective comparison of angiographic and myocardial perfusion imaging criteria for completeness

BACKGROUND

Coronary revascularization in patients with coronary artery disease may be guided by coronary angiography (CA) or alternatively by ischemia on stress myocardial perfusion imaging (MPI). Which strategy leads to optimal cardiac outcomes is uncertain.

METHODS

We performed a retrospective analysis of 170 patients with MPI ischemia and percutaneous coronary intervention. The primary endpoint was all-cause mortality at a mean follow-up of 47 ± 21 months; the secondary end point was the composite of deaths, nonfatal myocardial infarction, and repeat coronary revascularization (MACE). The coronary revascularization was defined as complete (CCR) or incomplete (ICR) as judged by CA criteria and by MPI ischemia matched with CA criteria.

RESULTS

Nighty-two patients (54%) had ICR by CA criteria (ICR-CA) and 84 (49%) had ICR by MPI criteria (ICR-MPI). Mortality and MACE were lower in patients with CCR-MPI than with ICR-MPI (P = .048, and P = .025). Survival of patients with CCR-CA and ICR-CA was not different (P = .081). Patients with both ICR-MPI and ICR-CA had the worst survival, whereas patients with CCR-MPI and CCR-CA had the best survival (P = .047). By multivariate analysis, ICR-MPI + ICR-CA was an independent predictor of death (P = .025).

CONCLUSION

Patients with ICR by MPI were at higher risk than those with CCR. Patients with both ICR by MPI and CA were at the highest risk, while patients with CCR by both MPI and CA had the best long-term event-free survival.

Invasive versus conservative strategy in patients aged 80 years or older with non-ST-elevation myocardial infarction or unstable angina pectoris (After Eighty study): an open-label randomised controlled trial

BACKGROUND

Non-ST-elevation myocardial infarction (NSTEMI) and unstable angina pectoris are frequent causes of hospital admission in the elderly. However, clinical trials targeting this population are scarce, and these patients are less likely to receive treatment according to guidelines. We aimed to investigate whether this population would benefit from an early invasive strategy versus a conservative strategy.

METHODS

In this open-label randomised controlled multicentre trial, patients aged 80 years or older with NSTEMI or unstable angina admitted to 16 hospitals in the South-East Health Region of Norway were randomly assigned to an invasive strategy (including early coronary angiography with immediate assessment for percutaneous coronary intervention, coronary artery bypass graft, and optimum medical treatment) or to a conservative strategy (optimum medical treatment alone). A permuted block randomisation was generated by the Centre for Biostatistics and Epidemiology with stratification on the inclusion hospitals in opaque concealed envelopes, and sealed envelopes with consecutive inclusion numbers were made. The primary outcome was a composite of myocardial infarction, need for urgent revascularisation, stroke, and death and was assessed between Dec 10, 2010, and Nov 18, 2014. An intention-to-treat analysis was used. This study is registered with ClinicalTrials.gov, number NCT01255540.

FINDINGS

During a median follow-up of 1·53 years of participants recruited between Dec 10, 2010, and Feb 21, 2014, the primary outcome occurred in 93 (40·6%) of 229 patients assigned to the invasive group and 140 (61·4%) of 228 patients assigned to the conservative group (hazard ratio [HR] 0·53 [95% CI 0·41-0·69], p=0·0001). Five patients dropped out of the invasive group and one from the conservative group. HRs for the four components of the primary composite endpoint were 0·52 (0·35-0·76; p=0·0010) for myocardial infarction, 0·19 (0·07-0·52; p=0·0010) for the need for urgent revascularisation, 0·60 (0·25-1·46; p=0·2650) for stroke, and 0·89 (0·62-1·28; p=0·5340) for death from any cause. The invasive group had four (1·7%) major and 23 (10·0%) minor bleeding complications whereas the conservative group had four (1·8%) major and 16 (7·0%) minor bleeding complications.

INTERPRETATION

In patients aged 80 years or more with NSTEMI or unstable angina, an invasive strategy is superior to a conservative strategy in the reduction of composite events. Efficacy of the invasive strategy was diluted with increasing age (after adjustment for creatinine and effect modification). The two strategies did not differ in terms of bleeding complications.

FUNDING

Norwegian Health Association (ExtraStiftelsen) and Inger and John Fredriksen Heart Foundation.

Clinical and angiographic outcomes associated with surgical revascularization of angiographically borderline 50-69% coronary artery stenoses

OBJECTIVES

Coronary artery bypass grafting (CABG) improves outcomes in patients with multivessel coronary artery disease. Bypass of angiographically significant lesions ≥70% is recommended, yet little is known about the incidence/outcomes with bypasses of 50-69% angiographically borderline lesions (ABLs) without fractional flow reserve testing. The objective of this study was to investigate the incidence and outcomes of bypass of 50-69% ABLs.

METHODS

Between 2007 and 2013, 3195 patients underwent isolated first multivessel CABG. Patients with an isolated ABL of a major epicardial vessel were included. Outcomes of interest included time to all-cause mortality, and 30-day and 1-year mortality.

RESULTS

Among 350 patients with an ABL, 268 (76.6%) had the vessel containing the ABL bypassed, while 82 (23.4%) did not. The mean follow-up was 4.2 years. Patients with a bypassed ABL were older (66.1 vs 62.5 mean years, P = 0.006) but otherwise similar in sex, comorbidities, diabetes, ejection fraction and number of coronary stenoses. Cardiopulmonary bypass time was longer in patients with bypassed ABLs (104.2 vs 90.4 min, mean, P < 0.001). Unadjusted overall mortality until the end of follow-up was higher among patients with bypassed ABLs (11.6 vs 3.7%, P = 0.034). After multivariable adjustment, the association between ABL bypass and mortality was attenuated (hazard ratio 2.84, 95% confidence interval: 0.87-9.23, P = 0.080). No differences were observed in unadjusted 30-day (1.1 vs 0.0%, P = 0.336) or 1-year mortality (4.1 vs 0.0%, P = 0.062). Repeat revascularization rate of patients with bypassed ABLs was numerically higher (4.1 vs 0.0%, P = 0.107).

CONCLUSIONS

In an unselected cohort of patients with ABLs, bypass of borderline 50-69% lesions is frequently performed and not associated with improved long-term survival. Our findings suggest that the routine surgical revascularization of 50-69% ABLs may not be warranted.

Risk of major adverse cardiovascular events in patients with metabolic syndrome after revascularization: A meta-analysis of eighteen cohorts with 18,457 patients

OBJECTIVE

To provide a comprehensive evaluation of the association between metabolic syndrome (MetS) and major adverse cardiovascular events (MACE) and to clarify the effect of revascularization methods among them in patients with coronary artery disease (CAD) undergoing successful revascularization.

METHODS

PubMed and Embase databases were searched. Cohort studies evaluating the association between MetS and risk of MACE and providing the hazard ratio (HR) with 95% confidence interval (CI) or sufficient data to calculate HR and its 95%CI among patients after revascularization were included. The pooled estimates were performed by using a random-effects model despite heterogeneity. Subgroup and sensitivity analyses were also conducted adherence to guidelines.

RESULTS

Eighteen trials with 18457 patients were included. Overall, MetS was associated with significant increased risks of MACE (HR 1.47, 95%CI 1.26-1.72, I(2)=46.4%, PH=0.016, P<0.001) and all-cause mortality (HR 1.58, 95%CI 1.29-1.92, I(2)=45.6%, PH=0.075, P<0.001) in CAD patients received revascularization. The results remained stable and robust in our subgroup analysis. However, no significant increased risk of MACE or all-cause mortality was found in patients undergoing coronary artery bypass graft (CABG) or drug-eluting stent (DES) in the sensitivity analysis.

CONCLUSION

MetS was associated with increased risks of MACE and all-cause mortality in patients after revascularization, but not in patients receiving CABG or DES. Therefore, prevention and treatment of MetS are extremely necessary in patients undergoing revascularization. Moreover, CABG and DES should be recommended for CAD patients with MetS and future researches are still warranted.

Transmyocardial laser revascularization versus medical therapy for refractory angina

BACKGROUND

This is an update of a review previously published in 2009. Chronic angina and advanced forms of coronary disease are increasingly more frequent. In spite of the improvement in the efficacy of available revascularization treatments, a subgroup of patients continue suffering from refractory angina. Transmyocardial laser revascularization (TMLR) has been proposed to improve the clinical situation of these patients.

OBJECTIVES

To assess the effects (both benefits and harms) of TMLR versus optimal medical treatment in people with refractory angina who are not candidates for percutaneous coronary angioplasty or coronary artery bypass graft, in alleviating angina severity, reducing mortality and improving ejection fraction.

SEARCH METHODS

We searched the following resources up to June 2014: the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, the metaRegister of Controlled Trials database, ClinicalTrials.gov, and the WHO International Clinical Trials Registry. We applied no languages restrictions. We also checked reference lists of relevant papers.

SELECTION CRITERIA

We selected studies if they fulfilled the following criteria: randomized controlled trials (RCTs) of TMLR, by thoracotomy, in patients with Canadian Cardiovascular Society or New York Heart Association angina grade III-IV who were excluded from other revascularization procedures.

DATA COLLECTION AND ANALYSIS

Three authors independently extracted data for each trial about the population and interventions compared and assessed the risk of bias of the studies, evaluating randomisation sequence generation, allocation concealment, blinding (of participants, personnel and outcome assessors), incomplete outcome data, selective outcome reporting, and other potential sources of bias.

MAIN RESULTS

From a total of 502 references, we retrieved 47 papers for more detailed evaluation. We selected 20 papers, reporting data from seven studies, which included 1137 participants, of which 559 were randomized to TMLR. Participants and professionals were not blinded, which suggests high risk of performance bias. Overall, 43.8% of participants in the treatment group decreased two angina classes, as compared with 14.8% in the control group: odds ratio (OR) 4.63, 95% confidence interval (CI) 3.43 to 6.25), and heterogeneity was present. Mortality by intention-to-treat analysis was similar in both groups at 30 days (4.0% in the TMLR group and 3.5% in the control group), and one year (12.2% in the TMLR group and 11.9% in the control group). However, the 30-day mortality as-treated was 6.8% in the TMLR group and 0.8% in the control group (pooled OR was 3.76, 95% CI 1.63 to 8.66), mainly due to a higher mortality in participants crossing from standard treatment to TMLR. The assessment of subjective outcomes, such as improvement in angina, was affected by a high risk of bias and this may explain the differences found. Other adverse events such as myocardial infarction, arrhythmias or heart failure, were not considered in this review, as they were not predefined outcomes in trials design and they show a high inconsistency across studies. No new trials on transmyocardial laser revascularization have been published in the last ten years and it is very unlikely that new research will be undertaken in this field.

AUTHORS' CONCLUSIONS

This review shows that risks associated with TMLR outweigh the potential clinical benefits. Subjective outcomes are subject to high risk of bias and no differences were found in survival, but a significant increase in postoperative mortality and other safety outcomes suggests that the procedure may pose unacceptable risks.

Relationship of body mass index with total mortality, cardiovascular mortality, and myocardial infarction after coronary revascularization: evidence from a meta-analysis

OBJECTIVE

To investigate the relationship of body mass index (BMI) with total mortality, cardiovascular (CV) mortality, and myocardial infarction (MI) after coronary revascularization procedures (coronary artery bypass grafting [CABG] and percutaneous coronary intervention [PCI]).

PATIENTS AND METHODS

Systematic search of studies was conducted using PubMed, CINAHL, Cochran CENTRAL, Scopus, and the Web of Science databases. We identified studies reporting the rate of MI, CV mortality, and total mortality among coronary artery disease patients' postcoronary revascularization procedures in various BMI categories: less than 20 (underweight), 20-24.9 (normal reference), 25-29.9 (overweight), 30-34.9 (obese), and 35 or more (severely obese). Event rates were compared using a random effects model assuming interstudy heterogeneity.

RESULTS

A total of 36 studies (12 CABG; 26 PCI) were selected for final analyses. The risk of total mortality (relative risk [RR], 2.59; 95% CI, 2.09-3.21), CV mortality (RR, 2.67; 95% CI, 1.63-4.39), and MI (RR, 1.79; 95% CI, 1.28-2.50) was highest among patients with low BMI at the end of a mean follow-up period of 1.7 years. The risk of CV mortality was lowest among overweight patients (RR, 0.81; 95% CI, 0.68-0.95). Increasing degree of adiposity as assessed by BMI had a neutral effect on the risk of MI for overweight (RR, 0.92; 95% CI, 0.84-1.01), obese (RR, 0.99; 95% CI, 0.85-1.15), and severely obese (RR, 0.93; 95% CI, 0.78-1.11) patients.

CONCLUSION

After coronary artery disease revascularization procedures (PCI and CABG), the risk of total mortality, CV mortality, and MI was highest among underweight patients as defined by low BMI and CV mortality was lowest among overweight patients.

Desphospho-uncarboxylated matrix Gla-protein is associated with mortality risk in patients with chronic stable vascular disease

BACKGROUND

Vitamin K is the essential co-factor for activation of matrix Gla-protein (MGP), the natural inhibitor of tissue calcification. Biologically inactive, desphospho-uncarboxylated MGP (dp-ucMGP) is a marker of vascular vitamin K status and is described to predict mortality in patients with heart failure and aortic stenosis. We hypothesized that increased dp-ucMGP might be associated with mortality risk in clinically stable patients with chronic vascular disease.

MATERIALS AND METHODS

We examined 799 patients (mean age 65.1 ± 9.3 years) who suffered from myocardial infarction, coronary revascularization or first ischemic stroke (pooled Czech samples of EUROASPIRE III and EUROASPIRE-stroke surveys), and followed them in a prospective cohort study. To estimate the 5-year all-cause and cardiovascular mortality we ascertained vital status and declared cause of death. Circulating dp-ucMGP and desphospho-carboxylated MGP (dp-cMGP) were measured by ELISA methods (IDS and VitaK).

RESULTS

During a median follow-up of 2050 days (5.6 years) 159 patients died. In the fully adjusted multivariate Cox proportional hazard model, the patients in the highest quartile of dp-ucMGP (≥ 977 pmol/L) had higher risk of all-cause and cardiovascular 5-year mortality [HRR 1.89 (95% CI, 1.32-2.72) and 1.88 (95% CI, 1.22-2.90)], respectively. Corresponding HRR for dp-cMGP were 1.76 (95% CI, 1.18-2.61) and 1.79 (95% CI, 1.12-2.57).

CONCLUSIONS

In patients with overt vascular disease, circulating dp-ucMGP and dp-cMGP were independently associated with the risk of all-cause and cardiovascular mortality. Since published results are conflicting regarding the dp-cMGP, we propose only circulating dp-ucMGP as a potential biomarker for assessment of additive cardiovascular risk.

Revascularisation versus medical treatment in patients with stable coronary artery disease: network meta-analysis

OBJECTIVE

To investigate whether revascularisation improves prognosis compared with medical treatment among patients with stable coronary artery disease.

DESIGN

Bayesian network meta-analyses to combine direct within trial comparisons between treatments with indirect evidence from other trials while maintaining randomisation.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

A strategy of initial medical treatment compared with revascularisation by coronary artery bypass grafting or Food and Drug Administration approved techniques for percutaneous revascularization: balloon angioplasty, bare metal stent, early generation paclitaxel eluting stent, sirolimus eluting stent, and zotarolimus eluting (Endeavor) stent, and new generation everolimus eluting stent, and zotarolimus eluting (Resolute) stent among patients with stable coronary artery disease.

DATA SOURCES

Medline and Embase from 1980 to 2013 for randomised trials comparing medical treatment with revascularisation.

MAIN OUTCOME MEASURE

All cause mortality.

RESULTS

100 trials in 93,553 patients with 262,090 patient years of follow-up were included. Coronary artery bypass grafting was associated with a survival benefit (rate ratio 0.80, 95% credibility interval 0.70 to 0.91) compared with medical treatment. New generation drug eluting stents (everolimus: 0.75, 0.59 to 0.96; zotarolimus (Resolute): 0.65, 0.42 to 1.00) but not balloon angioplasty (0.85, 0.68 to 1.04), bare metal stents (0.92, 0.79 to 1.05), or early generation drug eluting stents (paclitaxel: 0.92, 0.75 to 1.12; sirolimus: 0.91, 0.75 to 1.10; zotarolimus (Endeavor): 0.88, 0.69 to 1.10) were associated with improved survival compared with medical treatment. Coronary artery bypass grafting reduced the risk of myocardial infarction compared with medical treatment (0.79, 0.63 to 0.99), and everolimus eluting stents showed a trend towards a reduced risk of myocardial infarction (0.75, 0.55 to 1.01). The risk of subsequent revascularisation was noticeably reduced by coronary artery bypass grafting (0.16, 0.13 to 0.20) followed by new generation drug eluting stents (zotarolimus (Resolute): 0.26, 0.17 to 0.40; everolimus: 0.27, 0.21 to 0.35), early generation drug eluting stents (zotarolimus (Endeavor): 0.37, 0.28 to 0.50; sirolimus: 0.29, 0.24 to 0.36; paclitaxel: 0.44, 0.35 to 0.54), and bare metal stents (0.69, 0.59 to 0.81) compared with medical treatment.

CONCLUSION

Among patients with stable coronary artery disease, coronary artery bypass grafting reduces the risk of death, myocardial infarction, and subsequent revascularisation compared with medical treatment. All stent based coronary revascularisation technologies reduce the need for revascularisation to a variable degree. Our results provide evidence for improved survival with new generation drug eluting stents but no other percutaneous revascularisation technology compared with medical treatment.

Impact of myocardial ischemia on myocardial revascularization in stable ischemic heart disease. Lessons from the COURAGE and FAME 2 trials

In patients with stable ischemic heart disease (SIHD), myocardial revascularization should be performed to either improve survival or improve symptoms and functional status among patients who are not well controlled with optimal medical therapy (OMT). A general consensus exists on the core elements of OMT, which include both lifestyle intervention and intensive secondary prevention with proven pharmacotherapies. By contrast, however, there is less general agreement as to what constitutes the optimal approach to revascularization in SIHD patients. The COURAGE and FAME 2 randomized trials form the foundation of the current clinical evidence base and raise the important question: "What is the impact of myocardial ischemia on myocardial revascularization in stable ischemic heart disease?"

Incomplete revascularization is associated with greater risk of long-term mortality after stenting in the era of first generation drug-eluting stents

The association between incomplete revascularization (IR) and long-term mortality after stenting in the era of drug-eluting stents is not well understood. In the present study, we test the hypothesis that IR is associated with a greater risk of long-term (5-year) mortality after stenting for multivessel coronary disease. Using data from the Percutaneous Coronary Intervention Reporting System of New York State, 21,767 patients with multivessel disease who underwent stenting during October 2003 to December 2005 were identified. Complete revascularization (CR) was achieved in 6,844 patients (31.4%), and 14,923 patients (68.6%) were incompletely revascularized. The CR and IR patients were propensity matched on a 1:1 ratio on the number of diseased vessels, the presence of total occlusion, type of stents, and the probability of achieving CR estimated using a logistic model with established risk factors as independent variables. Patients were followed for vital status until December 31, 2008 using the National Death Index. Differences in survival between the matched CR and IR patients were compared. Among the 6,511 pairs of propensity-matched patients, the 5-year survival rate for IR was lower compared with CR (79.3% vs 81.4%, p = 0.004), and the risk of death during follow-up was 16% greater for IR compared with CR (hazard ratio 1.16, 95% confidence interval 1.06 to 1.27, p = 0.001). In addition, subgroup analyses demonstrated that the association between IR and long-term mortality was not dependent on major patient risk factors. In conclusion, IR is associated with an increased risk of long-term mortality after stenting for multivessel disease in the era of drug-eluting stents.

Does clinical presentation affect outcome among patients with acute coronary syndromes undergoing percutaneous coronary intervention? Insights from the Providing Regional Observations to Study Predictors of Events in the Coronary Tree study

BACKGROUND

In some prior studies, patients with ST-elevation myocardial infarction (STEMI) as compared with patients with non-STEMI (NSTEMI) tended to have a higher early mortality but similar long-term outcomes. We compared the angiographic and intravascular ultrasound (IVUS) characteristics of patients with STEMI and NSTEMI in the PROSPECT study to evaluate the independent prognostic value of clinical presentation on long-term outcome.

METHODS

After successful revascularization, patients had 3-vessel quantitative coronary angiography, gray scale, and radiofrequency intravascular ultrasound (IVUS) imaging. The primary end point was the occurrence of major adverse cardiac events (MACE) (cardiac death, myocardial infarction, or rehospitalization for unstable or progressive angina).

RESULTS

There were 211 patients (31.6%) with STEMI and 457 (68.4%) with NSTEMI. Patients with STEMI and NSTEMI had similar angiographic and IVUS morphologic characteristics. At 3 years, MACE occurred in 22.1% and 19.6%, respectively (hazard ratio [HR] 1.16 [0.81, 1.68], P = .42). There was a higher overall mortality (HR 2.16 [0.94, 4.99], P = .06) and a significantly higher incidence of probable stent thrombosis (HR 4.34 [1.09, 17.36], P = .02) in the STEMI cohort. There were no significant differences between the 2 groups with respect to events related to culprit or to nonculprit lesions. ST-elevation myocardial infarction presentation was not an independent predictor of 3-year MACE (HR 1.14 [0.77, 1.67], P = .52).

CONCLUSION

Patients with STEMI and NSTEMI did not differ with respect to residual nonculprit lesion angiographic or IVUS characteristics and had similar rates of MACE at 3 years, without late "catch-up" in NSTEMI. However, probable stent thrombosis and mortality were higher in the STEMI cohort.

The functional SYNTAX score - a huge step forward or research in motion?

In a recent manuscript in the Journal of the American College of Cardiology, the newly introduced "functional SYNTAX score" (FSS) was found to be a better tool to assess the extent and severity of coronary artery disease than the SYNTAX score (SS) and has reclassified 1/3 of the studied cohort into lower-risk categories. Besides being more invasive, costly, and time consuming, FSS still suffers from inherent deficiencies of its own. Like SS, FSS does not incorporate clinical risk predictors and consequently is a suboptimal tool for predicting PCI risk. FSS is not supported by a wealth of contemporary outcome data in a wide range of patient and lesions subsets. Key unanswered questions are whether PCI of hemodynamically significant lesions (FFR <0.80) is superior to optimal medical therapy (OMT) and whether complete revascularization yields considerably better outcomes than partial revascularization. Since partial revascularization is still an option, operational FSS (taking into account only the FSS of lesions subject to PCI) combined with a clinical risk score will probably better predict the procedural risk of the planned PCI.

Early vs. delayed invasive strategy in patients with acute coronary syndromes without ST-segment elevation: a meta-analysis of randomized studies

Although early percutaneous coronary intervention has been demonstrated to reduce the risk of mortality in patients with non-ST-segment elevation acute coronary syndromes (NSTE-ACS), there are emerging conflicting data as to whether the catheterization needs to be done very early or whether it could be delayed while the patient receives medical therapy. The aim of the current study was to perform a meta-analysis of randomized controlled trials (RCTs) comparing early vs. delayed invasive strategies for NSTE-ACS patients. Medline/CENTRAL and the Web were searched for RCTs comparing early vs. delayed invasive strategies for NSTE-ACS patients. The primary endpoint was all cause mortality, whereas myocardial infarction (MI), coronary revascularizations and 30-day major bleeding complications were secondary end points. Fixed or random effects models were used based on statistical heterogeneity. As a sensitivity analysis, Bayesian random effects meta-analysis was performed in addition to the classical random effects meta-analysis. A total of 5 RCTs were finally included, enrolling 4155 patients. As compared with a delayed strategy, an early invasive approach did not significantly reduce the rates of death [odds ratio (OR) 95% confidence interval (95% CI) = 0.81 (95% CI 0.60-1.09), P = 0.17], MI [OR = 1.18 (95% CI 0.68-2.05), P = 0.55] or revascularizations [OR = 0.97 (0.77-1.24), P = 0.82]. There was a not significant trend toward fewer major bleeding complications for the early invasive approach [OR (95% CI) = 0.76 (0.55-1.04), P = 0.08]. The present meta-analysis shows that for NSTE-ACS patients a routine early invasive strategy does not significantly improve survival nor reduce MI and revascularization rates as compared with a delayed approach.

[Anesthetic maintenance during myocardial revascularization in patients over 70 years of age]

The authors performed a comparative retrospective analysis of preoperative and intraoperative periods in 50 patients aged 70-83 years with coronary heart disease (CHD). A control group comprised the similar patients aged 40-59 years. The geriatric patients showed a higher incidence of arterial hypertension, respiratory and central nervous system diseases, cardiac arrhythmias, and anemia as an outcome. In CHD patients aged 70-80 years, balanced general anesthesia based on lower-dose midazolam and fentanyl, on subnarcotic-dose ketamine during the metered use of isoflurane and adequate infusion therapy provided reasonable hemodynamic stability during the induction of anesthesia and the preperfiusion period without administering cardiotonic agents. Intraoperatively, there was a more pronounced reduction in pulmonary oxygenizing function, body temperature and more needs for cardiotonic and diuretic therapy and erythrocyte mass after the basic stage of surgery.

Quantity of viable myocardium required to improve survival with revascularization in patients with ischemic cardiomyopathy: A meta-analysis

BACKGROUND

This meta-analysis was conducted to determine optimal cutoff values for the assessment of viability using various imaging techniques for which revascularization would offer a survival benefit in patients with ischemic cardiomyopathy (ICM).

METHODS AND RESULTS

We searched five electronic databases to identify relevant studies through December 2008. Relative risks of cardiac death, both in patients with and without viability, were calculated in each study. In order to estimate the optimal threshold for the presence of viability, we assumed a linear relationship between the amount of viable myocardium and survival benefit of revascularization. Twenty-nine studies (4,167 patients) met the inclusion criteria. The optimal threshold for the presence of viability was estimated to be 25.8% (95% CI: 16.6-35.0%) by positron emission tomography using 18F-fluorodeoxyglucose-perfusion mismatch, 35.9% (95% CI: 31.6-40.3%) by stress echocardiography using contractile reserve or ischemic responses, and 38.7% (95% CI: 27.7-49.7%) by single photon emission computed tomography using thallium-201 or technetium-99m MIBI myocardial perfusion.

CONCLUSIONS

The calculated amount of viable myocardium determined to lead to improved survival was different among imaging techniques. Thus, separate cutoff values for imaging modalities may be helpful in determining which patients with ICM benefit from revascularization.

Off-pump coronary artery bypass surgery can be completed safely in high risk patients

BACKGROUND

Off-pump coronary artery bypass (OPCAB) grafting has the potential to reduce morbidity and mortality, compared to on-pump cardiac surgery.

AIM

We compared the early results of OPCAB lateral and posterior wall revascularisations in 'low', 'intermediate' and 'high' risk patients as defined by the EuroSCORE system.

METHODS

Eighty-nine patients who underwent OPCAB with lateral and posterior wall revascularisation from January 2006 to December 2008 were included in this study. Patients were allocated to one of the three risk groups according to the EuroSCORE system: low, moderate and high risk groups. Perioperative and early postoperative results of the three groups were compared.

RESULTS

Significantly fewer patients required prolonged ICU stay in the low risk group, compared to moderate (19.4 vs. 50%) and high risk groups (19.4 vs. 36.7%). In addition, prolonged mechanical ventilation was more common in moderate (39.3 vs. 9.7%) and high risk groups (36.7 vs. 9.7%), compared to the low risk group. However, the groups did not differ in terms of mortality or other perioperative outcomes.

CONCLUSIONS

Our results suggest that in patients who are considered high risk on the basis of the EuroSCORE model and have diseased vessels on the lateral and/or posterior walls of the heart suitable for grafting, the early outcomes with OPCAB are similar to those in medium or low EuroSCORE risk category. The EuroSCORE model may overestimate the risk for OPCAB procedures.

Revascularization options in patients with chronic kidney disease

Cardiovascular disease is the leading cause of death in patients who have chronic kidney disease or end-stage renal disease and are undergoing hemodialysis. Chronic kidney disease is a recognized risk factor for premature atherosclerosis. Unfortunately, most major randomized clinical trials that form the basis for evidence-based use of revascularization procedures exclude patients who have renal insufficiency. Retrospective, observational studies suggest that patients with end-stage renal disease and severe coronary occlusive disease have a lower risk of death if they undergo coronary revascularization rather than medical therapy alone. Due to a lack of prospective studies, however, the relative merits of percutaneous versus surgical revascularization are merely a matter of opinion. Several small, retrospective studies have shown that coronary artery bypass grafting is associated with higher procedural death but better long-term survival than is percutaneous coronary intervention. This difference appears to result from poor long-term results of percutaneous coronary intervention in patients who have chronic kidney disease or end-stage renal disease.Because randomized trials comparing percutaneous coronary intervention and coronary artery bypass grafting have included patients undergoing balloon angioplasty and placement of bare-metal stents, their conclusions are suspect in the era of drug-eluting stents. In this review, we discuss different revascularization options for patients with chronic kidney disease, the outcomes of revascularization procedures, and the risk factors for adverse outcomes.

Therapeutic implications of low lymphocyte count in non-ST segment elevation acute coronary syndromes

BACKGROUND

Low lymphocyte count (LLC), a surrogate for inflammation, has emerged as a potential risk factor for cardiovascular outcomes, especially new ischemic events. To identify patients with non-ST segment elevation acute coronary syndromes (NSTEACS) who benefit from an invasive revascularization strategy remains a challenge. We sought to determine if patients with high-risk NSTEACS who exhibited LLC have a greater reduction in long-term post-discharge myocardial infarction (MI) when managed under a revascularization invasive strategy (RIS) as compared with conservative strategy (CS).

METHODS

Nine hundred seventy two consecutive patients with high-risk NSTEACS were treated under two revascularization strategies (RS): 1) CS, from January 2001 to October 2002 (345 patients; 35.5%) and 2) RIS, from November 2002 to May 2005 (627 patients; 64.5%). LLC was defined as lymphocytes count < or =1200 cells/ml (1 vs. 2-4 quartiles). The association between the type of RS and MI was stratified by lymphocyte count status and assessed by Cox regression adapted for competing events.

RESULTS

At 3-year follow-up, 145 deaths (14.9%), 135 MI (13.9%) and 76 revascularization procedures (7.8%) were registered. In a multivariable setting, LLC patients exhibited a greater MI risk reduction when managed under RIS (HR: 0.40; 95% CI=0.22-0.72, p=0.003). Conversely, when LLC was not present, no difference in the rate of MI was detected between the two RS.

CONCLUSIONS

LLC identifies a subgroup of patients with greater reduction in the risk of postdischarge MI when a RIS is applied.

High-risk myocardial infarction patients appear to derive more mortality benefit from short door-to-balloon time than low-risk patients

OBJECTIVES

To evaluate reduction of door-to-balloon (DTB) time and its impact on in-hospital mortality of high-risk infarct patients in a collaboration of district general hospitals (DGH) with a physician-to-patient model.

METHODS

Primary percutaneous coronary interventions (PPCI) with short DTB time offer mortality benefit for ST-segment elevation myocardial infarction but literatures are conflicting on this benefit for high- vs. low-risk patients. In a unique model at Sandwell and West Birmingham Hospitals, five interventional cardiologists provide 24-h PPCI at whichever one of its two DGH that patients present to. A retrospective audit was performed on 3 years (July 2005-June 2008) of PPCI data in the British Cardiovascular Intervention Society database. Data were analysed in four periods corresponding to change from daytime-only to 24-h PPCI. DTB time and in-hospital mortality were the main outcome measures.

RESULTS

Of the 459 patients, median DTB time improved from 89 min (interquartile range: 49-120) to 68 min (50-91) (p = 0.005) and proportion of patients achieving target 90-min DTB time increased from 53% (21/40) to 75% (93/124) (p = 0.005). In-hospital mortality was less for short DTB time [4.6% (13/284) vs. 11.5% (20/174); odds ratio (OR) 0.37, 95% confidence interval (CI): 0.18-0.75; p = 0.008]. With the proviso that our study was limited in power, long DTB time (> 90 min vs. < or = 90 min) was associated with higher in-hospital mortality in high-risk patients [15.6% (20/128) vs. 7.1% (12/168); OR 2.41, 95% CI: 1.14-5.06; p = 0.024] and not in low-risk patients [0% (0/46) vs. 0.9% (1/117); OR 0, 95% CI: 0-9.88; p = 1.000].

CONCLUSIONS

A collaboration of DGH with a physician-to-patient model can deliver timely PPCI that appear to translate into mortality benefit more so in high-risk patients. Low-risk patients would therefore probably tolerate delays associated with transfer to large centres while high-risk patients would not and need alternative strategy. A collaboration of smaller hospitals with a pool of mobile interventional cardiologists could be such an alternative.

Recent evolution in demographic and clinical characteristics and in-hospital morbidity in patients undergoing coronary surgery

BACKGROUND

Over the last 12 years, the demographic and clinical characteristics of patients undergoing myocardial revascularization surgery have evolved rapidly. The goal of our study was to analyze the evolution of these trends and the results of these surgical interventions.

METHODS

We identified patients who underwent a first or second myocardial revascularization between 1993 and 2004, and we arbitrarily divided them into 2 groups: 1 cohort of patients who underwent surgery between 1993 and 1998 and 1 cohort of patients who underwent surgery between 1999 and 2004. We compared demographic and clinical characteristics between the 2 cohorts and determined which variables were significant predictors of morbidity and mortality.

RESULTS

From 1993 to 2004, 12 202 patients underwent a first (95.5%) or second (4.5%) myocardial revascularization. Patients in the later cohort presented with a high-risk profile. They were older and had metabolic syndrome or diabetes and peripheral vascular disease. On the other hand, there were fewer active smokers in this group. Whereas the rate of postoperative infarction and renal insufficiency was higher in the second cohort, this group had a lower incidence of stroke and prolonged mechanical ventilation and shorter hospital stays. Overall, observed mortality decreased in spite of a steady increase in predicted mortality. Identified predictors of mortality were age, stroke, female sex, nonelective surgery, renal insufficiency, peripheral vascular disease, chronic obstructive pulmonary disease, ventricular dysfunction and stenosis of the left main trunk.

CONCLUSION

Our study confirmed current trends that show an increase in the at-risk population with dysmetabolic syndrome in cardiac surgery, as well as constant improvements in tertiary care in anesthesia and coronary surgery.

Coronary artery bypass grafting within 30 days after treatment of acute myocardial infarctions with angioplasty or fibrinolysis – a surgical substudy of DANAMI‐2

OBJECTIVE

To calculate the incidence and analyse the indications and outcome after surgical revascularization within the first 30 days after randomization of 1572 patients with acute myocardial infarction (MI) associated with ST-segment elevation (STEMI).

DESIGN

Data regarding the patients undergoing heart surgery within the first 30 days after randomization were collected.

RESULTS

Three patients (0.2%) with acute STEMI and randomized to percutaneous coronary intervention (PCI) underwent emergent coronary artery bypass grafting (CABG). A total of 50 patients (3.2%), 30 in the PCI group and 20 in the fibrinolysis group were revascularized by surgery within the first 30 days after randomization. The most frequent indication for surgery in both groups was unstable angina pectoris, followed by left main stenosis. The incidence of postoperative complications was higher compared with the outcome after elective CABG.

CONCLUSIONS

The incidence of emergency CABG in this study was low (0.2%) after treatment of acute MI with either PCI or fibrinolysis. The overall incidence within 30 days was 3.2%, however, the mortality is increased with a 30-day mortality of 10% in this high-risk patient group.