Paclitaxel drug-coated balloon-only angioplasty for de novo coronary artery disease in elective clinical practice

OBJECTIVE

We aimed to investigate the safety of drug-coated balloon (DCB)-only angioplasty compared to drug-eluting stent (DES), as part of routine clinical practice.

BACKGROUND

The recent BASKETSMALL2 trial demonstrated the safety and efficacy of DCB angioplasty for de novo small vessel disease. Registry data have also demonstrated that DCB angioplasty is safe; however, most of these studies are limited due to long recruitment time and a small number of patients with DCB compared to DES. Therefore, it is unclear if DCB-only strategy is safe to incorporate in routine elective clinical practice.

METHODS

We compared all-cause mortality and major cardiovascular endpoints (MACE), including unplanned target lesion revascularisation (TLR) of all patients treated with DCB or DES for first presentation of stable angina due to de novo coronary artery disease between 1st January 2015 and 15th November 2019. Data were analysed with Cox regression models and cumulative hazard plots.

RESULTS

We present 1237 patients; 544 treated with DCB and 693 treated with DES for de novo, mainly large-vessel coronary artery disease. On multivariable Cox regression analysis, only age and frailty remained significant adverse predictors of all-cause mortality. Univariable, cumulative hazard plots showed no difference between DCB and DES for either all-cause mortality or any of the major cardiovascular endpoints, including unplanned TLR. The results remained unchanged following propensity score-matched analysis.

CONCLUSION

DCB-only angioplasty, for stable angina and predominantly large vessels, is safe compared to DES as part of routine clinical practice, in terms of all-cause mortality and MACE, including unplanned TLR.

Assessment of Paclitaxel Drug-Coated Balloon Only Angioplasty in STEMI

BACKGROUND

Primary percutaneous coronary intervention (pPCI) with drug-eluting stents (DES) has emerged as the standard of care, but stent-related events have persisted. Drug-coated balloon (DCB)-only angioplasty is an emerging technology, although it is not fully evaluated compared with DES in the context of pPCI.

OBJECTIVES

The aim of this study was to investigate the safety of DCB-only angioplasty compared with second-generation DES in pPCI.

METHODS

All-cause mortality and net adverse cardiac events (cardiovascular mortality, acute coronary syndrome, ischemic stroke or transient ischemic attack, major bleeding, and unplanned target lesion revascularization [TLR]) were compared among all patients treated with DCBs only or with second-generation DES only for first presentation of ST-segment elevation myocardial infarction (STEMI) due to de novo disease between January 1, 2016, and November 15, 2019. Patients treated with both DCBs and DES were excluded. Data were analyzed using Cox regression models, Kaplan-Meier estimator plots and propensity score matching.

RESULTS

Among 1,139 patients with STEMI due to de novo disease, 452 were treated with DCBs and 687 with DES. After a median follow-up period of >3 years, all-cause mortality was 49 of 452 and 62 of 687 in the DCB and DES groups, respectively (P = 0.18). On multivariable Cox regression analysis, there was no difference in mortality between DCBs and DES in the full and propensity score-matched cohorts. Age, frailty risk, history of heart failure, and family history of ischemic heart disease remained significant independent predictors of mortality. There was no difference in any of the secondary endpoints, including unplanned TLR.

CONCLUSIONS

DCB-only angioplasty appears safe compared with DES for STEMI in terms of all-cause mortality and all net adverse cardiac events, including unplanned TLR. DCB may be an efficacious and safe alternative to DES in selected patient groups. (Drug Coated Balloon Only vs Drug Eluting Stent Angioplasty; NCT04482972).

Outcomes of drug coated balloon only angioplasty for stable angina in routine clinical practice

Introduction

The recent BASKETSMALL2 trial demonstrated safety and efficacy of drug coated balloon (DCB) angioplasty for de novo small vessel disease. Registry data have demonstrated that DCB angioplasty is safe; however, the majority of these studies are limited due to long recruitment time and small number of patients with DCB compared to drug eluting stents (DES).

Our aim was to investigate if DCB-only strategy is safe to incorporate in routine clinical practice.

Methods

We identified all patients treated for stable angina and de novo disease in our institution from January 2015 till November 2019. During that period an equivalent number of patients were treated with DCB-only or DES-only strategy on a yearly basis.

The primary endpoint was all cause mortality. The secondary endpoints were cardiovascular mortality, acute coronary syndrome (ACS), ischaemic stroke, major bleeding and target lesion revascularisation (TLR). Data were obtained from the hospital episodes statistics from NHS digital. Clinical and angiographic data were collected from our prospectively collated database and supplemented from electronic records as required. All angiograms were reviewed to confirm accuracy of angiographic data and determine TLR.

On multivariable COX regression analysis (Table 1) age, frailty and hypercholesterolaemia were the only independent predictors of all cause mortality.

Results

A total of 1302 patients were identified. HES data were not obtained for 65 patients who had opted-out, therefore 1237 were included in the analysis; 544 were treated with DCB and 693 with DES. The average age for the DCB-group was 67.9±10.2 years old (79% male); while for the DES group it was 67.9±9.7 years old (78.1% male). The average follow up was 1339±514 days and 1354±527 days for the DCB and DES group respectively. Table 1 shows the differences between the groups in terms of clinical and angiographic characteristics. The DES group had more patients with history of COPD (6.3% vs 3%; p=0.01) and larger average vessel diameter (3.46±0.58 vs 3.09±0.53mm; p<0.001). The DCB group had more patients with true bifurcation disease and TIMI 0 or 1 pre-PCI (11.6% vs 8.1%; p=0.04) and TIMI 0 or 1 pre-PCI (11.7% vs 6.6%; p=0.001). Furthermore, more than 70% of patients in the DCB group had vessel diameter ≥3mm indicating that large vessels were treated.

The all cause mortality was 35 (6.4%) and 59 (8.5%) for the DCB and DES group respectively. Kaplan Meier estimator plot did not show a significant difference between the groups. There was no difference between the groups in any of the secondary endpoints (cardiovascular mortality, ACS, stroke, major bleeding and TLR).

Conclusion

Our real world data from a large, contemporary cohort of stable angina patients, including predominantly large vessels, demonstrate that DCB only angioplasty is safe compared to DES in terms of all major cardiovascular endpoints including TLR.

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): B Braun - investigator initiated research

Optical Coherence Tomographic Study of a Chronically Retained Coronary Guidewire

Guidewire entrapment is a rare complication of coronary intervention, and management depends on the individual circumstances. This is a case of an urgent percutaneous coronary angioplasty in which a guidewire became entrapped behind a bare metal stent with subsequent fracture of the core filament, which could not be retrieved. Using optical coherence tomography, our case demonstrates extensive tissue coverage of the retained guidewire at twelve months. Five-year follow-up suggests that retained guidewires can be managed without long-term anticoagulation, even when there is substantial intra-aortic material.

Limited clinical utility of Holter monitoring in patients with palpitations or altered consciousness: analysis of 8973 recordings in 7394 patients

AIMS

To determine the clinical utility of 24 hour Holter monitoring by measuring the frequency of candidate arrhythmias recorded during the investigation of palpitations and altered consciousness.

METHODS

Of 9,729 Holter recordings, reports were available in 8,973 (92.2%) performed in the 7394 patients who comprise the study group. The mean age of the study group was 66 +/- 19 years and 56.4% were women.

RESULTS

The most common indications were altered consciousness (41.7%) and palpitations (36.2%). Among patients with palpitations and sinus rhythm (n=2688), recordings were normal in 2247 (83.6%). Abnormalities included paroxysmal atrial fibrillation (PAF, 6.6%), narrow complex tachycardia (NCT, 2.8%) nonsustained or sustained ventricular tachycardia (NSVT/VT, 2.6%). Among patients with altered consciousness (n=3075), recordings were normal in 2589 (84.2%). Abnormalities included PAF (9.5%), NCT (2.6%), NSV/VT (0.2%), pause >2.8s (2.2%) and high degree AV block (1.3%). The diagnostic yield of Holter monitoring was particularly low in patients aged < or =50 years, of whom 93.1% had palpitations and 95.3% had altered consciousness had normal recordings.

CONCLUSIONS

The diagnostic utility of Holter monitoring in patients being investigated for palpitations and altered consciousness is very limited, particularly in young patients for whom alternative diagnostic methods should be considered.

Ivabradine -- the first selective sinus node I(f) channel inhibitor in the treatment of stable angina

Heart rate, a major determinant of angina in coronary disease, is also an important predictor of cardiovascular mortality. Lowering heart rate is therefore one of the most important therapeutic approaches in the treatment of stable angina pectoris. To date, beta-blockers and some calcium-channel antagonists reduce heart rate, but their use may be limited by adverse reactions or contraindications. Heart rate is determined by spontaneous electrical pacemaker activity in the sinoatrial node controlled by the I(f) current. Ivabradine is the first specific heart rate-lowering agent that has completed clinical development for stable angina pectoris. It is selective for the I(f) current, lowering heart rate at concentrations that do not affect other cardiac ionic currents. Specific heart-rate lowering with ivabradine reduces myocardial oxygen demand, simultaneously improving oxygen supply. Ivabradine has no negative inotropic or lusitropic effects, preserving ventricular contractility, and does not change any major electrophysiological parameters unrelated to heart rate. Randomised clinical studies in patients with stable angina show that ivabradine effectively reduces heart rate, improves exercise capacity and reduces the number of angina attacks. It has superior anti-anginal and anti-ischaemic activity to placebo and is non-inferior to atenolol and amlodipine. Ivabradine therefore offers a valuable approach to lowering heart rate exclusively and provides an attractive alternative to conventional treatment for a wide range of patients with confirmed stable angina.

Declining case fatality rates for acute myocardial infarction in South Asian and white patients in the past 15 years

OBJECTIVES

To determine whether case fatality rates in South Asian (Bangladeshi, Indian and Pakistani) patients with acute myocardial infarction have shown similar declines to those reported for white patients during the past 15 years.

DESIGN

Cross-sectional, observational study.

SETTING

Coronary care unit in east London.

PATIENTS

2640 patients-29% South Asian-admitted with acute myocardial infarction between January 1988 and December 2002.

MAIN OUTCOME MEASURES

Differences over time in rates of in-hospital death, ventricular fibrillation and left ventricular failure.

RESULTS

The proportion of South Asians increased from 22% in 1988-92 to 37% in 1998-2002. Indices of infarct severity were similar in South Asian and white patients, with declining frequencies of ST elevation infarction (88.2% to 77.5%, p < 0.0001), Q wave development (78.1% to 56.9%, p < 0.0001) and mean (interquartile range) peak serum creatine kinase concentrations (1250 (567-2078) to 1007 (538-1758) IU/l, p < 0.0001) between 1988-92 and 1998-2002. Rates of in-hospital death (13.0% to 9.4%, p < 0.01), ventricular fibrillation (9.2% to 6.0%, p < 0.001) and left ventricular failure (33.2% to 26.5%, p < 0.0001) all declined; these changes did not interact significantly with ethnicity. Odds ratios for the effect of time on risk of death increased from 0.81 (95% CI 0.70 to 0.93) to 1.02 (95% CI 0.87 to 1.21) after adjustment for ethnicity and indices of infarct severity (ST elevation, peak creatine kinase, Q wave development and treatment with a thrombolytic).

CONCLUSIONS

In the past 15 years, death from acute myocardial infarction among South Asians has declined at a rate similar to that seen in white patients. This is largely caused by reductions in indices of infarct severity.