Comparison of procedural and clinical outcomes between optical coherence tomography and intravascular ultrasound guided percutaneous coronary intervention for patients with acute coronary syndrome

HomeCirculationVol. 135, No. 9Letter by Nadir Regarding Article, “Optical Coherence Tomography to Optimize Results of Percutaneous Coronary Intervention in Patients With Non-ST-Elevation Acute Coronary Syndrome: Results of the Multicenter, Randomized DOCTORS Study (Does Optical Coherence Tomography Optimize Results of Stenting)” Free AccessLetterPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessLetterPDF/EPUBLetter by Nadir Regarding Article, “Optical Coherence Tomography to Optimize Results of Percutaneous Coronary Intervention in Patients With Non-ST-Elevation Acute Coronary Syndrome: Results of the Multicenter, Randomized DOCTORS Study (Does Optical Coherence Tomography Optimize Results of Stenting)” M. Adnan Nadir, MD, MBBS, MRCP M. Adnan NadirM. Adnan Nadir From University Hospital Birmingham, United Kingdom. Search for more papers by this author Originally published28 Feb 2017https://doi.org/10.1161/CIRCULATIONAHA.116.025486Circulation. 2017;135:e138–e139To the Editor:I read the article by Meneveau et al1 with great interest. The authors concluded that in patients with non-ST-elevation myocardial infarction, optical coherence tomography-guided percutaneous coronary intervention (PCI) is associated with higher postprocedure fractional flow reserve (FFR) than PCI guided by angiography alone without an increase in periprocedural complications.Several concerns surround the use of FFR as a surrogate end point. The utility of FFR is firmly established in stable coronary artery disease but has been widely debated in patients with non-ST-elevation myocardial infarction, particularly in the culprit vessel.2 Valid FFR measurements require maximal coronary hyperemia, which may be less readily achieved in patients with acute coronary disease because of coronary microvascular dysfunction. This in turn may result in a falsely higher FFR value. This outcome is of particular concern when assessing the FFR value after PCI because coronary stenting of a thrombus-laden acute plaque of the culprit lesion in acute coronary syndrome would inevitably carry the risk of some distal embolization, which may further exacerbate the issue. In fact, in this study, 47% to 69% of the patients were noticed to have a discernable thrombus (either angiographically or on optical coherence tomography), and 50% of all participants received GP IIb/IIIa inhibitors. Both of these observations suggest that a legitimate and valid concern existed among the operators regarding the possibility of distal embolization and slow or no-flow phenomenon to account for the unusually high use of GP IIb/IIIa inhibitors. The authors reported that 79% of the patients had tissue protrusion and 43% received overdilatation after stent placement in the optical coherence tomography group. Hence, it is plausible that the higher FFR value seen in the optical coherence tomography group could have been caused by less hyperemia achieved in a distal vascular bed, which is overloaded with microembolization caused by more aggressive overdilatation after stent placement, compared with the angiographic group, which had a much lower rate of overdilataion after stent placement. Last but not least, the normal FFR value is considered to be 0.92 to 1.00, and a recent study investigating the utility of FFR after PCI reported that a FFR value < 0.91 was actually associated with a favorable outcome. Interestingly, in this study, despite the modest difference in absolute value, the mean FFR value after PCI was with in normal limits in both groups, which may further limit the value of FFR after PCI as the primary study outcome measure in this particular study.3M. Adnan Nadir, MD, MBBS, MRCPDisclosuresNone.FootnotesCirculation is available at http://circ.ahajournals.org.

To compare the prognosis of intravascular ultrasound (IVUS)-guided versus angiography-guided percutaneous coronary intervention (PCI) in patients with acute coronary syndrome (ACS). This retrospective cohort study included 190 ACS patients who underwent PCI between January 2019 and January 2024. Patients were equally divided into two groups: IVUS-guided (n=95) and angiography-guided PCI (n=95). Baseline characteristics, procedural details, and clinical outcomes were analyzed. Follow-up duration was one year. Primary endpoints included cardiac function parameters, target vessel-related events, major adverse cardiovascular and cerebrovascular events , and quality of life (QoL) measures. The IVUS-guided group demonstrated better procedural outcomes, with significantly lower stent volume (P=0.002) and reduced neointima volume at 9 months (P=0.002). Improvements in cardiac function were more notable in the IVUS group, reflected in lower post-treatment left ventricular end-diastolic volume index (P=0.004) and end-systolic volume index (P=0.003). QoL scores were significantly higher in physical function (P=0.001) and social function (.002). However, IVUS-guided procedures required longer procedural time and greater contrast media use. IVUS-guided PCI yields superior procedural precision, improved cardiac function, and better quality of life compared to angiography-guided PCI in ACS patients, with acceptable trade-offs in procedural complexity.

Intravascular Imaging-Guided Percutaneous Coronary Intervention in Patients With End-Stage Renal Disease on Maintenance Dialysis

Optical coherence tomography (OCT) is currently used as a guide for percutaneous coronary intervention (PCI), however its clinical benefit in comparison with intravascular ultrasound (IVUS) remains unclear in patients with acute coronary syndrome (ACS). The purpose of this study was to evaluate the clinical efficacy of OCT-guided PCI in comparison with IVUS-guided PCI in patients with ACS. The study participants comprised 280 consecutive ACS patients who underwent primary PCI for de novo culprit lesions under OCT or IVUS guidance. Compared with the IVUS-guided group, the OCT-guided group had lower Killip classification (p < 0.001) and lower creatinine level at baseline (0.80 ± 0.37 mg/dl vs. 1.13 ± 1.29 mg/dl, p = 0.004). Fluoroscopy time and total procedure time were significantly shorter in the OCT-guided group than in the IVUS-guided group (32 ± 13 min vs. 41 ± 19 min, p < 0.001, and 98 ± 39 min vs. 127 ± 47 min, p = 0.002, respectively). The major adverse cardiovascular event-free survival curves were similar between the OCT- and IVUS-guided groups after adjusting for clinical background using propensity score (log-rank p = 0.328). After adjusting for clinical background, OCT-guided PCI could provide comparable clinical outcomes to IVUS-guided PCI in patients with ACS. Shorter fluoroscopy time and total procedure time with OCT may reduce patient radiation exposure and also improve hospital workflow.

Reperfusion therapy via percutaneous coronary intervention (PCI) as the preferred method of treatment for an acute ST-segment–elevation myocardial infarction (STEMI) requires the use of potent antiplatelet agents (eg, aspirin, P2Y12 inhibitors, and GPIIb/IIIa antagonists) and anticoagulant therapies, including heparin or bivalirudin,1 both of which have potential risk of bleeding. An increased bleeding risk in some patients with STEMI makes the use of antiplatelet/anticoagulant agents a relative or absolute contraindication to PCI. Acute gastrointestinal bleed (GIB) in the acute coronary syndrome setting is a particularly vexing situation requiring the balancing of risk/benefit for each condition and a resultant high-risk decision for the treatment of either condition. Clinically significant GIB may present concomitantly in an estimated 1.3% of cases of acute coronary syndrome, based on the Acute Catheterization and Urgent Intervention Triage Strategy (ACUITY) trial.2 Guidance concerning optimal management and ensuing strategies in patients with STEMI and contraindications to antiplatelet/antithrombotic agents, specifically with respect to patients who present with parallel and active GIB from literature is scant at best. In this report, we discuss the challenges of managing competing treatment strategies in a patient who presents with concurrent STEMI and acute active GIB. ### Case Presentation A 68-year-old woman presented to the emergency room with severe nausea and vomiting, accompanied by extreme fatigue, dizziness, and light headedness. The symptoms began 7 hours earlier and had been gradually increasing in severity. Vomitus was nonbilious, nonbloody, without coffee ground appearance. She denied chest pain or pressure, palpitations, orthopnea, and reported only mild dyspnea. Two weeks before presentation, the patient described having melena. Her primary care physician documented hemoglobin of 5.1 g/dL. However, the patient refused a blood transfusion and preferred therapy with only iron infusion. An esophagogastroduodenoscopy revealed no abnormalities. Colonoscopic imaging was inconclusive because of inadequate gastrointestinal preparation. In 2011, the patient had PCI …

Optical coherence tomography-guided versus intravascular ultrasound-guided percutaneous coronary intervention in patients with acute myocardial infarction

Impact of Obstructive Sleep Apnea on Clinical and Angiographic Outcomes Following Percutaneous Coronary Intervention in Patients With Acute Coronary Syndrome

Ad Hoc Percutaneous Coronary Intervention After In-Laboratory High Dose Clopidogrel Loading for Clopidogrel-Naive Patients: Safe for All?

Objective The effect of postdilation in patients with acute coronary syndrome is still controversial. This meta-analysis aims to analyze the clinical and angiographic outcomes of postdilation after percutaneous coronary intervention in patients with acute coronary syndrome. Methods PubMed, Embase, the Cochrane Library, Web of Science, CNKI, and Wangfang databases were searched from inception to August 30, 2020. Eligible studies from acute coronary syndrome patients treated with postdilation were included. The primary clinical outcome was major adverse cardiovascular events (MACE), the secondary clinical outcomes comprised all-cause death, stent thrombosis, myocardial infarction, and target vessel revascularization, and the angiographic outcomes were no reflow and slow reflow. Results 11 studies met inclusion criteria. In clinical outcomes, our pooled analysis demonstrated that the postdilation had a tendency of decreasing MACE (OR = 0.67, 95% CI 0.45–1.00; P = 0.05) but significantly increased all-cause death (OR = 1.49, 95% CI 1.05–2.12; P = 0.03). No significant difference existed in stent thrombosis (OR = 0.71, 95% CI 0.40–1.26; P = 0.24), myocardial infarction (OR = 1.40, 95% CI 0.51–3.83; P = 0.51), and target vessel revascularization (OR = 0.61, 95% CI 0.21–1.80; P = 0.37) between postdilation and non-postdilation groups. In angiographic outcomes, there were no significant differences in no reflow (OR = 1.19, 95% CI 0.54–2.65; P = 0.66) and slow reflow (OR = 1.12, 95% CI 0.93–1.35; P = 0.24) between two groups. Conclusions The postdilation tends to reduce the risk of MACE but significantly increases all-cause death, without significantly affecting stent thrombosis, myocardial infarction, target vessel revascularization, and coronary TIMI flow grade. However, more randomized controlled trials are required for investigating the effect of postdilation for patients with acute coronary syndrome (registered by PROSPERO, CRD42020160748).

Objective Coronary intravascular imaging allows visualization and characterization of vessel wall. Percutaneous coronary intervention (PCI) using intravascular ultrasound or optical coherence tomography has optimized stent deployment techniques, reduced periprocedural outcomes and reduced long-term major cardiovascular events. We sought to investigate the outcomes of imaging guided to conventional angiography guided PCI with reference to in-hospital mortality, hospital length of stay (LOS) and total hospital charge. Methods We performed a retrospective cohort study using data from the 2016–2017 Nationwide Inpatient Sample (NIS) which is the largest collection of inpatient hospitalization data in the United States. Patients admitted with a principal diagnosis of acute coronary syndrome (ACS) who underwent PCI with and without intravascular imaging was determined using the International Classification of Diseases, Tenth revision codes. The primary outcome was inpatient mortality while secondary outcomes are showed in table 1. STATA software was used for the analysis. Multivariate logistic and linear regression models were used to adjust for confounders. Results There were over 71 million hospital discharges in the combined 2016 and 2017 NIS database. Admission for ACS in adult patients (aged ≥18 years) who underwent PCI yielded 622,855 results. Among this group, 27, 520 (4.4%) had imaging guided PCI while 595,335 (95.6%) had PCI without imaging. Patients with imaging guided PCI had lower inpatient mortality (3.2% vs 2.3%, AOR: 0.74, 95% CI 0.60–0.90, p=0.004) compared to PCI with angiographic data alone. Imaging guided PCI had an adjusted increased mean LOS of 0.16 days (3.8 vs 3.7 days, CI: 006–0.26, p=0.002) with an adjusted increased mean total hospital charge of $13, 206 ($120,203 vs $104,916, p= &amp;lt;0.0001). Conclusion Patients hospitalized for ACS who had imaging guided PCI had reduced inpatient hospital mortality compared to those who had PCI without imaging guidance. Overall utilization of imaging was less than 5% in 2016–2017, however it is expected to be higher in recent years with improvements in clinical practice, training and available scientific evidence. Funding Acknowledgement Type of funding sources: None.

<i>Circulation: Cardiovascular Interventions</i> Editors’ Picks

Intravascular imaging-guided versus angiography-guided percutaneous coronary intervention in patients with diabetes mellitus: Rationale and design of an international, multicenter, randomized IVI-DIABETES trial.

Rationale and design of the TACTICS registry: Optical coherence tomography guided primary percutaneous coronary intervention for patients with acute coronary syndrome

Objectives We aim to evaluate long-term outcomes after left main coronary artery (LMCA) percutaneous coronary intervention (PCI) in patients presenting with acute coronary syndrome (ACS). Background PCI of the LMCA has been an acceptable revascularization strategy in stable coronary artery disease. However, limited studies on long-term clinical outcomes of LMCA PCI in ACS patients are available. Methods A total of 6429 consecutive patients with ACS undergoing PCI in Fuwai Hospital in 2013 were enrolled. Patients are divided into LMCA group and Non-LMCA group according to whether the target lesion was located in LMCA. Prognosis impact on 2-year major adverse cardiovascular and cerebrovascular events (MACCE) is analyzed. Results 155 (2.4%) patients had target lesion in LMCA, while 6274 (97.6%) patients belong to the non-LMCA group. Compared with non-LMCA patients, LMCA patients have generally more comorbidities and worse baseline conditions. Two-year follow-up reveals that LMCA patients have significantly higher rate of cardiac death (2.6% vs. 0.7%, p = 0.034), myocardial infarction (7.1% vs. 1.8%, p < 0.001), in-stent thrombosis (4.5% vs. 0.8%, p < 0.001), and stroke (7.1% vs. 6.4%, p = 0.025). After adjusting for confounding factors, LMCA remains independently associated with higher 2-year myocardial infarction rate (HR = 2.585, 95% CI = 1.243–5.347, p = 0.011). Conclusion LMCA-targeted PCI is an independent risk factor for 2-year myocardial infarction in ACS patients.

Objective To explore the value of Age, Creatinine and Ejection Fraction Score (ACEF Score) in assessing the risk of revascularization within 6 months after percutaneous coronary intervention (PCI) in patients with acute coronary syndrome (ACS). Methods This was a retrospective study. The 1 002 ACS patients who received PCI in the First Affiliated Hospital of Air Force Medical University from January 2015 to December 2017 were divided into case group and control group according to whether PCI revascularization was performed within 6 months. We collected the patients' clinical data, including gender, age, cardiovascular history, diabetes history, smoking history, GRACE score, heart rate, systolic blood pressure, electrocardiogram, echocardiography, cardiac function, coronary angiography results and drug use. The ACEF score was calculated and the patients were stratified according to the score results (low score: ACEF≤1, middle score: 1 1.3). The clinical data and angiographic results of patients with different ACE stratification were compared. Kaplan-Meier survival analysis was used to compare the occurrence of revascularization within 6 months after PCI in ACS patients with different layers. Results The ACEF score of patients in the case group was significantly higher than that of the control group (1.18±0.34 vs. 1.05±0.32, t=6.235, P 1.3 groups, the proportion of diabetes mellitus was higher in the case group (both P<0.01). The higher the ACEF score, the higher the risk of readmission in ACS patients 6 months after PCI (P<0.01). Conclusions ACEF score can be used to assess the risk of revascularization in ACS patients within 6 months after PCI. Key words: Age, creatinine and ejection fraction score; Acute coronary syndrome; Angioplasty, transluminal, percutaneous coronary; Patient readmission