AI-Based Detection of Coronary Artery Occlusion Using Acoustic Biomarkers Before and After Stent Placement

<i>Circulation</i> Editors’ Picks

The SYNTAX score according to diabetic status: What does it mean for the patient requiring myocardial revascularization?

Is Percutaneous Coronary Intervention Now the Default Revascularization Strategy for Unprotected Left Main Coronary Artery Stenosis?

<i>Circulation</i> Editors’ Picks

As stated in American College of Cardiology/American Heart Association Guidelines, randomized trials have not demonstrated that elective percutaneous coronary intervention (PCI) reduces myocardial infarction (MI) or mortality over medical treatment. Even the Fractional Flow Reserve Guided PCI Versus Medical Therapy in Stable Coronary Disease (FAME 2) trial showed no statistically significant benefit of PCI over the deferred group by traditional intention-to-treat, nonbenchmark analysis starting at randomization that includes procedure-related events. Benchmark analysis in FAME 2 beginning 1 week after PCI removed procedure-related events that counterbalanced subsequent reduced MI and mortality compared with the deferred group. Meta-analysis of the literature on risk of events related to fractional flow reserve (FFR), including FFR Versus Angiography in Multivessel Evaluation (FAME), and other physiological measures of severity reveal an underappreciated, powerful interdependence among physiological severity of stenosis, diffuse coronary artery disease (CAD), event rates, sample size, and statistical certainty of differences. This analytic review synthesizes an evidenced-based, quantitative hypothesis and potential solution to this issue based on hard data from the literature by coauthors of diverse cardiovascular disciplines in trial design, biostatistics, invasive procedures, coronary physiology, fluid dynamics, coronary pathology, and quantitative imaging. Our synthesis elucidates a dual hypothesis for failure of elective PCI in stable CAD to reduce MI or mortality and novel trial design for selecting patients for whom PCI will likely reduce these events. First, a large burden of global diffuse CAD carries a high risk of coronary events unmitigated by PCI of a focal stenosis. Second, focal stenosis severity in previous randomized revascularization trials has been too modest without objectively quantified sufficient severity to observe benefit of PCI. In previous trials, mixture of diffuse coronary disease and intermediate stenosis may not incur high enough risk for potential benefit by PCI for sample size of reported trials. Greater quantitative severity with …

Interventional therapy of coronary artery disease in China: retrospective and perspective

Surgical collateralization: The hidden mechanism for improving prognosis in chronic coronary syndromes

Alice K. Jacobs, MD, FACC, FAHA, Chair Jeffrey L. Anderson, MD, FACC, FAHA, Chair-Elect Nancy Albert, PhD, CCNS, CCRN, FAHA Mark A. Creager, MD, FACC, FAHA Steven M. Ettinger, MD, FACC Robert A. Guyton, MD, FACC Jonathan L. Halperin, MD, FACC, FAHA Judith S. Hochman, MD, FACC, FAHA

It was an important and indeed remarkable observation when several trials reported the consistent finding that dual antiplatelet therapy with aspirin and a thienopyridine was superior to aspirin and oral anticoagulation for prevention of major adverse cardiac events after deployment of a stent in a coronary artery.1 A major benefit of dual antiplatelet therapy was a lower rate of stent thrombosis. The incidence of coronary stent thrombosis in the modern era is reported to be approximately 1%, with an increased likelihood of occurrence in high-risk patient or lesion subsets. Although this rate may seem relatively low, stent thrombosis is associated with major myocardial infarction (MI) in 60% to 70% of cases, resulting in an early mortality rate of 20% to 25%. With increased use of percutaneous coronary intervention (PCI) as a revascularization strategy and implantation of stents in coronary arteries with a small diameter, it is anticipated that the number of patients at risk for stent thrombosis may increase. It therefore continues to be important to construct pharmacological regimens that minimize its occurrence. Several risk factors for stent thrombosis have been identified, including patient- and/or lesion-specific characteristics, procedure-related factors, and inherent stent thrombogenicity.2 These risk factors, in turn, contribute to a state of enhanced platelet reactivity and thrombus formation, which promotes abrupt vessel closure. See p 1153 Although initial studies highlighting the benefits of dual antiplatelet therapy used aspirin and ticlopidine, clopidogrel is the thienopyridine of choice today because it is associated with a lower rate of intolerable side effects. It is noteworthy that clopidogrel as part of the dual antiplatelet regimen to support PCI has not undergone the type of extensive evaluation demanded of ACE inhibitors, angiotensin receptor blockers, or such devices as implantable cardioverter-defibrillators before they were recommended in practice guidelines for management of patients with …

Despite the efforts of investigators, public health andprivate caregivers, voluntary health organizations,and policymakers, heart disease continues to be the leading cause of death in women, both in the United States and throughout most of the world.1,2 A number of issues contribute to these disappointing statistics. Many women lack the basic awareness that cardiovascular disease is the leading cause of death among women. The American Heart Association’s (AHA) 2004 survey of women’s attitudes and knowledge showed that, when asked what they thought was the leading cause of death among women, 50 % of women answered this question incorrect-ly.3 Even more important, only 13 % of women personalized this information and answered that their own personal great-est health threat was heart disease. Although this level has increased from 7 % since the initial survey 6 years ago, it is still far too low. Furthermore, because coronary disease

The American Association for Thoracic Surgery and The Society of Thoracic Surgeons reasoning for not endorsing the 2021 ACC/AHA/SCAI Coronary Revascularization Guidelines

Identifying the Vulnerable Patient with Rupture-Prone Plaque

Among patients with coronary artery disease (CAD), there are widely divergent clinical practice styles in the use of myocardial revascularization, medical therapy, and the assessment of symptomatic or functional status after the initiation of treatment. Frequently, patients who have undergone initial successful revascularization, principally with percutaneous coronary intervention (PCI), are re-evaluated with diagnostic testing (both noninvasive and invasive) within the first year of follow-up, presumably to document objectively the absence of recurrent ischemia, despite the fact that current clinical practice guidelines proscribe such routine testing in otherwise asymptomatic individuals. Clearly, all clinicians seek to achieve optimal care for their patients, but both external pressures from payers and the need to conform to established treatment guidelines often create conflict and uncertainty in physician decision-making regarding what is right. Article see p 11 There should be general agreement that the best outcomes in patients with CAD are observed when comprehensive risk factor modification, intensive medical therapy, and appropriate use of revascularization are used in the setting of judicious clinical decision-making that is evidence based. Optimal medical therapy can be defined as that which uses guideline-directed, disease-modifying interventions (eg, aspirin with or without thienopyridines, statins, and inhibitors of the renin-angiotensin system) as well as therapeutic agents directed toward angina relief and control of ischemia (eg, β-blockers, calcium channel blockers, nitrates, or ranolazine—used alone or in combination).1 For patients with CAD who are symptomatic, antianginal therapy is not considered to be optimal unless at least 2 antianginal agents have been prescribed, and, generally, a desired, favorable treatment effect is achieved in sufficient doses. Similarly, stress testing in the patient with CAD may be performed for evaluation of ischemic symptoms, to assess prognostic risk or, when there is concern that a revascularization procedure has been incomplete, to assess the functional significance of residual obstructive …

Treatment Strategies in CKD Patients With Suspected Coronary Artery Disease

Ischemic heart disease is the leading cause of death globally. Coronary artery bypass graft (CABG) surgery and percutaneous coronary intervention (PCI) are the revascularization options for ischemic heart disease. However, the choice of the most appropriate revascularization modality is controversial in some patient subgroups. To summarize the current evidence comparing the effectiveness of CABG surgery and PCI in patients with unprotected left main disease (ULMD, in which there is >50% left main coronary stenosis without protective bypass grafts), multivessel coronary artery disease (CAD), diabetes, or left ventricular dysfunction (LVD). A search of OvidSP MEDLINE, EMBASE, and Cochrane databases between January 2007 and June 2013, limited to randomized clinical trials (RCTs) and meta-analysis of trials and/or observational studies comparing CABG surgery with PCI was performed. Bibliographies of relevant studies were also searched. Mortality and major adverse cardiac and cerebrovascular events (MACCE, defined as all-cause mortality, myocardial infarction, stroke, and repeat revascularization) were reported wherever possible. Thirteen RCTs and 5 meta-analyses were included. CABG surgery should be recommended in patients with ULMD, multivessel CAD, or LVD, if the severity of coronary disease is deemed to be complex (SYNTAX >22) due to lower cardiac events associated with CABG surgery. In cases in which coronary disease is less complex (SYNTAX ≤22) and/or the patient is a higher surgical risk, PCI should be considered. For patients with diabetes and multivessel CAD, CABG surgery should be recommended as standard therapy irrespective of the severity of coronary anatomy, given improved long-term survival and lower cardiac events (5-year MACCE, 18.7% for CABG surgery vs 26.6% for PCI; P = .005). Overall, the incidence of repeat revascularization is higher after PCI, whereas stroke is higher after CABG surgery. Current literature emphasizes the importance of a heart-team approach that should consider coronary anatomy, patient characteristics, and local expertise in revascularization options. Literature pertaining to revascularization options in LVD is scarce predominantly due to LVD being an exclusion factor in most studies. Both CABG surgery and PCI are reasonable options for patients with advanced CAD. Patients with diabetes generally have better outcomes with CABG surgery than PCI. In cases of ULMD, multivessel CAD, or LVD, CABG surgery should be favored in patients with complex coronary lesions and anatomy and PCI in less complicated coronary disease or deemed a high surgical risk. A heart-team approach should evaluate coronary disease complexity, patient comorbidities, patient preferences, and local expertise.