Clinical outcome up to 2 years after percutaneous coronary intervention in all-comers with concomitant symptomatic peripheral arterial disease: a pooled analysis in 9,204 randomized trial participants

Background

An increasing number of patients with coronary artery disease, who undergo percutaneous coronary intervention, also have symptomatic peripheral arterial disease. These patients have a worse long-term prognosis, but it is unclear whether the inferior outcome can be seen as early as during the first 2 years from coronary stenting.

Purpose

The aim of this study in all-comers was to evaluate the impact of symptomatic peripheral arterial disease on 1- and 2-year clinical outcome after coronary stenting.

Methods

Patient-level data from four large-scale randomised coronary drug-eluting stent trials in all-comers (TWENTE (clinicaltrials.gov: NCT01066650), DUTCH PEERS (NCT01331707), BIO-RESORT (NCT01674803), and BIONYX (NCT02508714)) were pooled to evaluate the impact of symptomatic peripheral arterial disease on clinical outcome after coronary stenting. Peripheral arterial disease was defined as a history (by anamnesis or medical record) of an obstructive arterial lesion, resulting from atherosclerosis in peripheral locations including the lower and upper extremities, carotid or vertebral arteries, and mesenteric or renal arteries. Main clinical endpoint was target vessel failure, a composite of cardiac death, target vessel related myocardial infarction, or clinically indicated target vessel revascularisation.

Results

Of all 9,204 trial participants, 695 (7.6%) had symptomatic peripheral arterial disease. These patients were older and had a higher cardiovascular risk profile, including a higher prevalence of diabetes, renal failure, hypertension, hypercholesterolemia, and prior stroke. At 1-year follow-up, patients with peripheral arterial disease showed significantly higher event rates of some endpoints. At 2-year follow-up, patients with peripheral arterial disease showed significantly higher rates of various clinical endpoints, including mortality (7.1% vs. 3.0%, p<0.001), myocardial infarction (4.8% vs. 3.4%, p0.04), repeated revascularisation (6.7% vs 4.5%, p<0.04), and major adverse cardiac events (14.6% vs. 8.3%, p<0.001, Figure 1). After multivariate adjustment for confounders, symptomatic peripheral arterial disease was found to be independently associated with the 2-year risks of target vessel and lesion failure, major adverse cardiac events, and all-cause death (p<0.02, for all, Table 1).

Conclusion

Obstructive coronary artery disease with concomitant symptomatic peripheral arterial disease resulted in higher cardiovascular risk profiles and higher rates of all-cause mortality and various composite clinical endpoints during the first two years of follow-up after coronary stenting. Knowledge of these findings allows to identify patients with an increased short- and medium-term adverse event risk after percutaneous coronary intervention, which is useful for both Heart Team and informed consent discussions.

Funding Acknowledgement

Type of funding sources: Other. Main funding source(s): The original trials were funded by Abbott Vascular, Medtronic, Boston Scientific and Biotronik.

Efficacy of mindfulness-based cognitive therapy on symptoms of depression and anxiety in patients with coronary artery disease: insights from a prospective registry

Introduction

Patients with coronary artery disease (CAD) report psychological distress and poor physical functioning after cardiovascular events. In cardiac rehabilitation, an exercise program is often used as A primary strategy; however, this is often not sufficient to address stress and psychosocial well-being.

Purpose

To investigate the effectiveness of a mindfulness-based cognitive therapy (MBCT) program on feelings of anxiety and depression in patients with CAD.

Methods

In this single-center prospective observational study, eligible cardiac rehabilitation patients with symptoms of anxiety or depression were recruited after referral for psychological consultation. During eight consecutive weeks, patients participated in group meetings. The program included psycho- education, cognitive behavioral therapy, meditation and slow abdominal breathing. Standard measures of depression, anxiety and blood pressure were obtained at baseline and after completion of the program. The Hospital Anxiety and Depression Scale (HADS) questionnaire was used as an instrument for detecting states of anxiety and depression.

Results

A total of 135 patients (mean age 56±9 years; 24% female) were enrolled. The mean HADS-Anxiety score improved from 11.0±3.7 at baseline to 6.6±3.4 after MBCT (p<0.001). The mean HADS-Depression score improved from 8.8±3.6 to 4.7±3.2 (p<0.001). In addition, during the MBCT program a significant decrease in blood pressure was noted: systolic from 140±18 to 130±17 mmHg and diastolic from 84±12 to 77±10 mmHg (p<0.001 for both).

Conclusion

This study provides evidence that a MBCT program has the potential to improve feelings of anxiety and depression in patients with CAD. Therefore, adding MBCT to cardiac rehabilitation in selected patients may be of great value.

Funding Acknowledgement

Type of funding sources: None.

Everolimus-eluting bioresorbable scaffolds and metallic stents in diabetic patients: a patient-level pooled analysis of the prospective ABSORB DM Benelux Study, TWENTE and DUTCH PEERS

Background

Several studies compared everolimus-eluting bioresorbable scaffolds (EE-BRS) with everolimus-eluting stents (EES), but only few assessed these devices in patients with diabetes mellitus.

Aim

To evaluate the safety and efficacy outcomes of all-comer patients with diabetes mellitus up to 2 years after treatment with EE-BRS or EES.

Methods

We performed a post hoc pooled analysis of patient-level data in diabetic patients who were treated with EE-BRS or EES in 3 prospective clinical trials: The ABSORB DM Benelux Study (NTR5447), TWENTE (NTR1256/NCT01066650) and DUTCH PEERS (NTR2413/NCT01331707). Primary endpoint of the analysis was target lesion failure (TLF): a composite of cardiac death, target vessel myocardial infarction or clinically driven target lesion revascularization. Secondary endpoints included major adverse cardiac events (MACE): a composite of all-cause death, any myocardial infarction or clinically driven target vessel revascularization, as well as definite or probable device thrombosis (ST).

Results

A total of 499 diabetic patients were assessed, of whom 150 received EE-BRS and 249 received EES. Total available follow-up was 222.6 patient years (PY) in the EE-BRS and 464.9 PY in the EES group. The adverse events rates were similar in both treatment groups for TLF (7.2 vs. 5.2 events per 100 PY, p = 0.39; adjusted hazard ratio (HR) = 1.48 (95% confidence interval (CI): 0.77–2.87), p = 0.24), MACE (9.1 vs. 8.3 per 100 PY, p = 0.83; adjusted HR = 1.23 (95% CI: 0.70–2.17), p = 0.47), and ST (0.9 vs. 0.6 per 100 PY, p > 0.99).

Conclusion

In this patient-level pooled analysis of patients with diabetes mellitus from 3 clinical trials, EE-BRS showed clinical outcomes that were quite similar to EES.

P6517Three-year clinical outcome of patients with abnormal glucose metabolism treated with contemporary drug-eluting stents

Background/Introduction

Patients with coronary artery disease that have an abnormal glucose metabolism are known to have more extensive and complex atherosclerotic coronary disease. In patients without previously known diabetes, abnormal glucose metabolism was shown to be independently associated with an up to four-fold higher event risk during the first year after percutaneous coronary intervention (PCI) with drug-eluting stents (DES).

Purpose

To examine the 3-year clinical outcome after stenting with contemporary DES in patients with abnormal glucose metabolism, either detected by oral glucose tolerance testing (OGTT) or by glycated haemoglobin A1c (HbA1c) and fasting plasma glucose.

Methods

The present analysis is a local substudy of the BIO-RESORT randomised trial. OGTT and HbA1c with fasting plasma glucose were prospectively assessed in 988 trial participants without previously known diabetes. The main clinical endpoint was target vessel failure, a composite of cardiac death, target vessel-related myocardial infarction or target vessel revascularisation at 3-years.

Results

In one out of three study participants (330/988), abnormal glucose metabolism was detected by either OGTT or HbA1c and fasting plasma glucose. Three-year follow up was available in 99.8% of these patients. The rate of target vessel failure was significantly higher in patients with abnormal glucose metabolism versus normoglycaemic patients (8.8% vs. 5.5%, p=0.044; Figure). This difference was driven by the incidence of periprocedural myocardial infarction that was higher in patients with abnormal glucose metabolism than in patients with normoglycaemia (4.5% vs. 1.4%, p=0.002).

Target vessel failure at 3-years

Conclusion

Abnormal glucose metabolism was associated with a significantly higher risk of target vessel failure at 3-years; this difference was driven by higher rates of periprocedural myocardial infarction.

Acknowledgement/Funding

The present substudy received no additional funding. The BIO-RESORT trial was equally funded by Biotronik, Boston Scientific, and Medtronic.