Benefit Of Percutaneous Coronary Intervention Research Articles

Late survival benefit of percutaneous coronary intervention compared with medical therapy in patients with coronary chronic total occlusion: a 10-year follow-up study

Abstract Background As an initial treatment strategy, percutaneous coronary intervention (PCI) for coronary chronic total occlusion (CTO) did not show mid-term survival benefits compared with optimal medical therapy (OMT). Purpose To compare 10-year clinical outcomes between OMT and PCI in CTO patients. Methods Between March 2003 and February 2012, 2,024 patients with CTO were enrolled in a single center registry and followed for about 10 years. We excluded CTO patients who underwent coronary artery bypass grafting, and classified patients into the OMT group (n=664) or PCI group (n=883) according to initial treatment strategy. Propensity-score matching was performed to minimize potential selection bias. The primary outcome was cardiac death. Results In the PCI group, 699 patients (79.2%) underwent successful revascularization. Clinical and angiographic characteristics revealed more comorbidities and more complex lesions in the OMT group than in the PCI group. At 10 years, the PCI group had lower risks of cardiac death (10.4% versus 22.3%; HR 0.43; 95% CI 0.32 to 0.57; p<0.001) than the OMT group. After the propensity-score matching analyses, the PCI group had lower risks of cardiac death (13.6% versus 20.8%; HR 0.62; 95% CI 0.44 to 0.88; p=0.007), acute myocardial infarction (6.3% versus 11.2%; HR 0.55; 95% CI 0.34 to 0.91; p=0.02), any revascularization (23.9% versus 32.2%; HR 0.67; 95% CI 0.51 to 0.88; p=0.004) than the OMT group. The beneficial effects of CTO PCI were consistent across various subgroups (all p-values for interaction: non-significant). Conclusions As an initial treatment strategy, PCI reduced late cardiac death compared with OMT in CTO patients. Cardiac death in matched population Funding Acknowledgement Type of funding source: None

Long-term impact of baseline anaemia on clinical outcomes following percutaneous coronary intervention in stable angina.

BackgroundIn patients with stable angina (SA), the clinical benefits of percutaneous coronary intervention (PCI) reside almost exclusively within the realm of symptomatic improvement rather than improvement in hard clinical endpoints. The benefits of PCI should always be balanced against its potential short-term and long-term risks. Common among these risks is the presence of anaemia and its interaction with poor clinical outcomes and increased morbidity; this study aims to elucidate the impact of anaemia on long-term clinical outcomes of this patient group.MethodsFrom Danish national registries, we identified patients with SA treated with PCI who had a haemoglobin measurement maximum of 90 days prior to PCI procedure. Anaemia was defined as haemoglobin <130 and <120 g/L in men and women, respectively. Follow-up was up to 3 years after PCI, and Cox regression was used to estimate HRs with 95% CIs of hospitalisation due to bleeding, acute coronary syndrome (ACS) and all-cause mortality in patients with anaemia compared with patients without anaemia.ResultsOf 2837 included patients, 14.6% had anaemia prior to PCI. During follow-up, 93 patients (3.3%) had a bleeding episode, which was higher in patients with anaemia (5.8%) compared with patients without anaemia (2.8%). A total of 213 patients (7.5%) developed ACS, which was higher in patients with anaemia (10.6%) compared with patients without anaemia (7.0%). Furthermore, 185 patients (6.5%) died, with a mortality rate of 18.1% in patients with anaemia compared with 4.5% in patients without anaemia. In multivariable analyses, anaemia was associated with a significantly increased risk of bleeding (HR 1.69; 95% CI 1.04 to 2.73; P 0.033), ACS (HR 1.47; 95% CI 1.04 to 2.10; P 0.031) and all-cause mortality (HR 2.41; 95% CI 1.73 to 3.30; P <0.001).ConclusionAnaemia in patients with SA was significantly associated with bleeding, ACS and all-cause mortality following PCI.

Non-invasive procedural planning using computed tomography-derived fractional flow reserve.

ObjectivesThis study aimed to investigate the performance of computed tomography derived fractional flow reserve based interactive planner (FFRCT planner) to predict the physiological benefits of percutaneous coronary intervention (PCI) as defined by invasive post‐PCI FFR.BackgroundAdvances in FFRCT technology have enabled the simulation of hyperemic pressure changes after virtual removal of stenoses.MethodsIn 56 patients (63 vessels) invasive FFR measurements before and after PCI were obtained and FFRCT was calculated using pre‐PCI coronary CT angiography. Subsequently, FFRCT and invasive coronary angiography models were aligned allowing virtual removal of coronary stenoses on pre‐PCI FFRCT models in the same locations as PCI was performed. Relationships between invasive FFR and FFRCT, between post‐PCI FFR and FFRCT planner, and between delta FFR and delta FFRCT were evaluated.ResultsPre PCI, invasive FFR was 0.65 ± 0.12 and FFRCT was 0.64 ± 0.13 (p = .34) with a mean difference of 0.015 (95% CI: −0.23–0.26). Post‐PCI invasive FFR was 0.89 ± 0.07 and FFRCT planner was 0.85 ± 0.07 (p < .001) with a mean difference of 0.040 (95% CI: −0.10–0.18). Delta invasive FFR and delta FFRCT were 0.23 ± 0.12 and 0.21 ± 0.12 (p = .09) with a mean difference of 0.025 (95% CI: −0.20–0.25). Significant correlations were found between pre‐PCI FFR and FFRCT (r = 0.53, p < .001), between post‐PCI FFR and FFRCT planner (r = 0.41, p = .001), and between delta FFR and delta FFRCT (r = 0.57, p < .001).ConclusionsThe non‐invasive FFRCT planner tool demonstrated significant albeit modest agreement with post‐PCI FFR and change in FFR values after PCI. The FFRCT planner tool may hold promise for PCI procedural planning; however, improvement in technology is warranted before clinical application.

Expert consensus on nursing management for patients undergoing primary percutaneous coronary intervention during the COVID-19 pandemic.

Expert consensus on nursing management for patients undergoing primary percutaneous coronary intervention during the COVID-19 pandemic.

Percutaneous coronary intervention versus medical therapy in patients with angina and grey-zone fractional flow reserve values: a randomised clinical trial

IntroductionThere is conflicting evidence regarding the benefits of percutaneous coronary intervention (PCI) in patients with grey zone fractional flow reserve (GZFFR artery) values (0.75–0.80). The prevalence of ischaemia is unknown....

Percutaneous Coronary Intervention in Stable Coronary Heart Disease -Is Less More?

This review concerns the putative benefit of percutaneous coronary intervention (PCI) over optimal medical therapy (OMT) for symptomatic patients with stable angina pectoris, or for asymptomatic persons in whom screening tests have revealed coronary heart disease (CHD; this entity has been newly designated chronic coronary syndrome, or CCS). Moreover, it addresses the question whether the indications for which PCI is now performed in Germany on patients with CCS are consistent with current scientific knowledge. The pathophysiological concept of CHD and ischemia induction is discussed in the light of the scientific literature. This concept implies that PCI might be beneficial in the treatment of CCS. The benefit of PCI over OMT has now been evaluated in seven randomized trials (the so-called milestone trials). The current situation in Germany is presented here as well, on the basis of the available data. The pathophysiological concept of CHD implies that the particular coronary artery stenoses that are likely to give rise to a myocardial infarction (the so-called vulnerable plaques) cannot be identified prospectively with current methods. Moreover, a coronary artery stenosis will not necessarily cause myocardial ischemia. All of the randomized trials carried out to date that have compared OMT to PCI-plus-OMT in patients with CCS have led to the conclusion that PCI, because it focuses on individual coronary artery stenoses, cannot prolong survival or lower the incidence of myocardial infarction over the long term. This remains the case even if a single coronary artery stenosis is known to be causing moderate or severe myocardial ischemia (a conclusion of the ISCHEMIA trial). A PCI performed only because the coronary stenosis or stenoses meet certain morphological criteria, without any demonstration of a resulting functional disturbance, is generally detrimental to the health of the patient, with rare exceptions, and is inconsistent with the recommendations of current guidelines. The number of PCIs being performed in Germany at present is high compared to other countries; this arouses concern that the indications for it may be dubious in many cases. Current data imply that PCI for CCS does not improve outcomes in a large percentage of cases. A symptomatic benefit exists only in patients with frequent angina pectoris. The selection of CCS patients for PCI needs to be more strictly bound to the recommendations of current guidelines, particularly in Germany.

Clinical impact of successful recanalization for chronic total occlusion: insights from stress myocardial perfusion imaging.

The clinical benefits of percutaneous coronary intervention (PCI) for chronic total occlusion (CTO) is still controversial. The purpose of this study is to assess the quantitative therapeutic benefits of successful PCI for CTO from the clinical data acquired by myocardial perfusion imaging (MPI). Consecutive 42 patients, who were successfully revascularized of CTO between August 2013 and March 2018, were examined. A stress MPI was performed before CTO PCI and at follow-up, and the changes in quantitative gated and perfusion single photon emission computed tomography parameters were examined. The follow-up interval was 18 ± 9 (median 14) months, during which 36 patients were maintained patency (patent CTO), while 6 were re-occluded (R/O CTO). The reduction in the % myocardial ischemia and the improvement in the ejection fraction were significantly higher in the patent CTO group than those in the R/O CTO group (67.5 ± 37.0% vs. - 56.4 ± 84.9%, p < 0.0001, 20.7 ± 49.8% vs. - 9.2 ± 20.6%, p = 0.0247, respectively). Interestingly, the improvements we observed were predominantly in the patients with LAD CTO rather than those with RCA or LCx CTO. Successful CTO PCI was able to reduce myocardial ischemia and improve the cardiac function when the patency after CTO PCI was maintained, with the most notable significance in the patients with LAD CTO.

Gender Differences in Endothelial Function and Coronary Vasomotion Abnormalities

Introduction: Structural and functional abnormalities of coronary microvasculature, referred to as coronary microvascular dysfunction (CMD), have been implicated in a wide range of cardiovascular diseases and have gained growing attention in patients with chest pain with no obstructive coronary artery disease, especially in females. The central mechanisms of coronary vasomotion abnormalities encompass enhanced coronary vasoconstrictive reactivity (ie, coronary spasm), reduced endothelium-dependent and -independent coronary vasodilator capacities, and increased coronary microvascular resistance. The 2 major endothelium-derived relaxing factors, nitric oxide (NO) and endothelium-dependent hyperpolarization (EDH) factors, modulate vascular tone in a distinct vessel size–dependent manner; NO mainly mediates vasodilatation of relatively large, conduit vessels, while EDH factors in small resistance vessels. Endothelium-dependent hyperpolarization–mediated vasodilatation is more prominent in female resistance arteries, where estrogens exert beneficial effects on endothelium-dependent vasodilatation via multiple mechanisms. In the clinical settings, therapeutic approaches targeting NO are disappointing for the treatment of various cardiovascular diseases, where endothelial dysfunction and CMD are substantially involved. Significance: In this review, we will discuss the current knowledge on the pathophysiology and molecular mechanisms of endothelial function and coronary vasomotion abnormalities from bench to bedside, with a special reference to gender differences. Results: Recent experimental and clinical studies have demonstrated distinct gender differences in endothelial function and coronary vasomotion abnormalities with major clinical implications. Moreover, recent landmark clinical trials regarding the management of stable coronary artery disease have questioned the benefit of percutaneous coronary intervention, supporting the importance of the coronary microvascular physiology. Conclusion: Further characterization and a better understanding of the gender differences in basic vascular biology as well as those in cardiovascular diseases are indispensable to improve health care and patient outcomes in cardiovascular medicine.

Cardiologists’ and patients’ views about the informed consent process and their understanding of the anticipated treatment benefits of coronary angioplasty: A survey study

Percutaneous coronary intervention is a common revascularisation technique. Serious complications are uncommon, but death is one of them. Seeking informed consent in advance of percutaneous coronary intervention is mandatory. Research shows that percutaneous coronary intervention patients have inaccurate perceptions of risks, benefits and alternative treatments. To assess cardiologists' and patients' views about the informed consent process and anticipated treatment benefits. Two cross-sectional, anonymous surveys were distributed in England: an electronic version to a sample of cardiologists and a paper-based version to patients recruited from 10 centres. A sample of 118 cardiologists and 326 patients completed the surveys. Cardiologists and patients shared similar views on the purpose of informed consent; however, over 40% of patients and over a third of cardiologists agreed with statements that patients do not understand, or remember, the information given to them. Patients placed less value than cardiologists on the consent process and over 60% agreed that patients depended on their doctor to make the decision for them. Patients' and cardiologists' views on the benefits of percutaneous coronary intervention were significantly different; notably, 60% of patients mistakenly believed that percutaneous coronary intervention was curative. The percutaneous coronary intervention informed consent process requires improvement to ensure that patients are more involved and accurately understand treatment benefits to make an informed decision. Redesign of the patient pathway is recommended to allow protected time for health professionals to engage in discussions using evidence-based approaches such as 'teach back' and decision support which improve patient comprehension.

Percutaneous coronary interventions for stable ischemic heart disease in Italy.

Although the benefits of percutaneous coronary interventions (PCIs) in patients with stable chronic ischemic heart disease (SIHD) are controversial, a large number of PCIs are currently performed in SIHD patients, frequently after coronary angiography (ad-hoc procedures), without the use of fractional flow reserve (FFR) to identify patients most likely to benefit from PCI. Assessment of regional variations in PCI for SIHD performed in Italy in 2017 and correlation of the regional number of PCI per million inhabitants with the use of FFR were performed using the data reported in the registry of the Italian Society of Interventional Cardiology (SICI-GISE) registry for the year 2017. PCI for SIHD accounted for 44.5% of all PCI performed in Italy with large variations among the Italian regions. There was a significant and inverse relationship between the use of FFR and the PCI number per million inhabitants performed for SIHD in the various Italian regions (P = 0.01). In the Veneto region, where local authorities mandated Heart Team reports to select the most appropriate treatment choice in multivessel disease patients, the rate of ad-hoc procedures was significantly lower than the national average. PCI for SIHD patients represent almost half of all procedures currently performed in Italy with regional variations inversely related to physiologic guidance use. The mandatory assessment by the Heart Team to select the most appropriate treatment choice in multivessel disease patients is associated with a significantly lower number of ad-hoc procedures.

TCT-231 Prognosis of Percutaneous Coronary Intervention Versus Optimal Medical Therapy in the Treatment of Chronic Total Coronary Occlusion: A Systematic Review and Meta-Analysis

Chronic total coronary occlusion (CTO) management remains a challenge. Several studies have reported the benefits of percutaneous coronary intervention (PCI) in CTO. However, the outcomes of PCI versus optimal medical therapy (OMT) are still controversial. We comprehensively searched the databases

Outcomes following percutaneous coronary intervention in patients with cancer

BackgroundRandomized clinical trials demonstrated the benefits of percutaneous coronary interventions (PCI) in diverse clinical settings. Patients with cancer were not routinely included in these studies. Methods/resultsLiterature search of PubMed, Cochrane, Medline, SCOPUS, EMBASE, and ClinicalTrials was conducted to identify studies that assessed one-year all-cause, cardiovascular and non-cardiovascular mortality in patients with historical or active cancer. Using the random effects model, we computed risk ratios (RRs) and standardized mean differences and their 95% confidence intervals for the dichotomous and continuous measures and outcomes, respectively. Of 171 articles evaluated in total, 5 eligible studies were included in this meta-analysis. In total, 33,175 patients receiving PCI were analyzed, of whom 3323 patients had cancer and 29,852 no cancer history. Patients in the cancer group had greater all-cause mortality [RR 2.22 (1.51–3.26; p<0.001)], including cardiovascular mortality [RR 1.34 (1.1–1.65; p=0.005)] and non-cardiovascular mortality [RR 3.42 (1.74–6.74; p≤0.001], at one-year compared to non-cancer patients. Patients in the cancer group had greater one-month all-cause mortality [RR 2.01 (1.24–3.27; p=0.005)] and greater non-cardiovascular mortality [RR 6.87 (3.10–15.21; p≤0.001)], but no difference in one-month cardiovascular mortality compared to non-cancer patients. Meta-regression analyses showed that the difference in one-year all-cause and cardiovascular mortality between both groups was not attributable to differences in baseline characteristics, index PCI characteristics, or medications prescribed at discharge. ConclusionsPatients with cancer undergoing PCI have worse mid-term outcomes compared to non-cancer patients. Cancer patients should be managed by a multi-specialist team, in an effort to close the mortality gap.

Percutaneous Coronary Intervention With Drug-Eluting Stent Versus Optimal Medical Therapy for Chronic Total Occlusion: Systematic Review and Meta-Analysis.

The optimal treatment strategy for coronary chronic total occlusion (CTO) has not been well established. The benefit of percutaneous coronary intervention (PCI) was inferred mainly from observational studies comparing successful versus failed PCI without a control group receiving optimal medical therapy (OMT). We conducted a systematic review and meta-analysis of randomized controlled trials (RCTs) and observational studies comparing PCI using drug-eluting stent (DES) versus OMT alone in patients with CTO. Eight studies were identified: 3 RCTs and 5 observational studies. Among a total of 4784 included patients, 2461 patients underwent PCI and 2323 patients received OMT. There was a significant association between PCI and lower cardiac mortality (odds ratio = 0.62; 95% confidence interval 0.42-0.93; P = .02). There was no significant difference between PCI and OMT regarding major adverse cardiac events, recurrent myocardial infarction (MI), repeat revascularization, or stroke. In the RCT subset (1399 patients), there was no significant difference between PCI and OMT regarding clinical outcomes. Compared with OMT alone, PCI with DES for CTO was associated with lower cardiac mortality, mainly driven by observational studies, without significant difference in recurrent MI or repeated revascularization. Further RCTs are needed to investigate the role of PCI for management of patients with CTO.

Drug-Eluting Stent Versus Coronary Artery Bypass Grafting for Diabetic Patients With Multivessel and/or Left Main Coronary Artery Disease: A Meta-Analysis.

With the development of stent design and surgical techniques, the relative benefit of percutaneous coronary intervention (PCI) versus coronary artery bypass grafting (CABG) in patients with diabetes and complex coronary artery disease are highly debated. This meta-analysis was conducted to compare the outcomes of drug-eluting stent (DES) implantation and CABG in these cohorts. A comprehensive search of PubMed, Embase, and Cochrane Library up to January 4, 2018, was performed. Only randomized controlled trials (RCTs), subgroup analysis from RCTs, or adjusted observational studies were eligible. Five RCTs and 13 adjusted observational studies involving 17 532 patients were included. Overall, PCI with DES was significantly associated with higher risk of all-cause mortality (hazard ratio [HR]: 1.16, 95% confidence interval [CI]: 1.05-1.29), myocardial infarction (MI; HR: 1.69, 95% CI: 1.43-2.00), and repeat revascularization (HR: 3.77, 95% CI: 2.76-5.16) compared with CABG. Nevertheless, the risk of stroke was significantly lower in the DES group (HR: 0.67, 95% CI: 0.54-0.83). The incidence of the composite end point of death, MI, or stroke was comparable between the 2 groups (HR: 0.99, 95% CI: 0.84-1.17). Despite the higher risk of stroke, CABG was better than PCI with DES for diabetic patients with multivessel and/or left main coronary artery disease.

Impact of Percutaneous Revascularization on Exercise Hemodynamics in Patients With Stable Coronary Disease

BackgroundRecently, the therapeutic benefits of percutaneous coronary intervention (PCI) have been challenged in patients with stable coronary artery disease (SCD). ObjectivesThe authors examined the impact of PCI on exercise responses in the coronary circulation, the microcirculation, and systemic hemodynamics in patients with SCD. MethodsA total of 21 patients (mean age 60.3 ± 8.4 years) with SCD and single-vessel coronary stenosis underwent cardiac catheterization. Pre-PCI, patients exercised on a supine ergometer until rate-limiting angina or exhaustion. Simultaneous trans-stenotic coronary pressure-flow measurements were made throughout exercise. Post-PCI, this process was repeated. Physiological parameters, rate-limiting symptoms, and exercise performance were compared between pre-PCI and post-PCI exercise cycles. ResultsPCI reduced ischemia as documented by fractional flow reserve value (pre-PCI 0.59 ± 0.18 to post-PCI 0.91 ± 0.07), instantaneous wave-free ratio value (pre-PCI 0.61 ± 0.27 to post-PCI 0.96 ± 0.05) and coronary flow reserve value (pre-PCI 1.7 ± 0.7 to post-PCI 3.1 ± 1.0; p < 0.001 for all). PCI increased peak-exercise average peak coronary flow velocity (p < 0.0001), coronary perfusion pressure (distal coronary pressure; p < 0.0001), systolic blood pressure (p = 0.01), accelerating wave energy (p < 0.001), and myocardial workload (rate-pressure product; p < 0.01). These changes observed immediately following PCI resulted from the abolition of stenosis resistance (p < 0.0001). PCI was also associated with an immediate improvement in exercise time (+67 s; 95% confidence interval: 31 to 102 s; p < 0.0001) and a reduction in rate-limiting angina symptoms (81% reduction in rate-limiting angina symptoms post-PCI; p < 0.001). ConclusionsIn patients with SCD and severe single-vessel stenosis, objective physiological responses to exercise immediately normalize following PCI. This is seen in the coronary circulation, the microcirculation, and systemic hemodynamics.

Predicting the Benefits of Percutaneous Coronary Intervention on 1-Year Angina and Quality of Life in Stable Ischemic Heart Disease: Risk Models From the COURAGE Trial (Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation).

Percutaneous coronary intervention (PCI) is a therapy to reduce angina and improve quality of life in patients with stable ischemic heart disease. However, it is unclear whether the quality of life after PCI is more dependent on the PCI or other patient-related factors. To address this question, we created models to predict angina and quality of life 1 year after PCI and medical therapy. Using data from the 2287 stable ischemic heart disease patients randomized in the COURAGE trial (Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation) to PCI plus optimal medical therapy (OMT) versus OMT alone, we built prediction models for 1-year Seattle Angina Questionnaire angina frequency, physical limitation, and quality of life scores, both as continuous outcomes and categorized by clinically desirable states, using multivariable techniques. Although most patients improved regardless of treatment, marked variability was observed in Seattle Angina Questionnaire scores 1 year after randomization. Adding PCI conferred a greater mean improvement (about 2 points) in Seattle Angina Questionnaire scores that were not affected by patient characteristics (P values for all interactions >0.05). The proportion of patients free of angina or having very good/excellent physical limitation (physical function) or quality of life at 1 year was 57%, 58%, 66% with PCI+OMT and 50%, 55%, 59% with OMT alone group, respectively. However, other characteristics, such as baseline symptoms, age, diabetes mellitus, and the magnitude of myocardium subtended by narrowed coronary arteries were as, or more, important than revascularization in predicting symptoms (partial R2=0.07 versus 0.29, 0.03 versus 0.22, and 0.05 versus 0.24 in the domain of angina frequency, physical limitation, and quality of life, respectively). There was modest/good discrimination of the models (C statistic=0.72-0.82) and excellent calibration (coefficients of determination for predicted versus observed deciles=0.83-0.97). The health status outcomes of stable ischemic heart disease patients treated by OMT+PCI versus OMT alone can be predicted with modest accuracy. Angina and quality of life at 1 year is improved by PCI but is more strongly associated with other patient characteristics. URL: https://www.clinicaltrials.gov. Unique identifier: NCT00007657.

MAJOR ADVERSE CARDIAC EVENTS OF REVASCULARIZATION IN CHRONIC TOTAL CORONARY OCCLUSION COMPARED TO OPTIMAL MEDICAL THERAPY: A SYSTEMATIC REVIEW AND META-ANALYSIS

Chronic total occlusion (CTO) management remains a challenge. Several studies have reported the benefits of percutaneous coronary intervention (PCI) in CTO. However, the outcomes of PCI versus optimal medical therapy (OMT) are still controversial. We conducted extensive reviews and meta-analysis to

Rethinking revascularization in patients with stable angina

ABSTRACTIntroduction: Traditional and current perception for benefit of percutaneous coronary intervention (PCI) is that patients with stable angina will obtain symptom relief as well as improved exercise capacity after percutaneous revascularization. This common clinical perception is put to test in the ORBITA trial, the first blinded, randomized placebo-controlled clinical study ever conducted.Areas covered: Coronary artery disease, percutaneous coronary intervention, medical therapy.Expert Commentary: The authors found no significant improvement in exercise time, functional status, angina relief and quality of life in the PCI group compared with placebo. A possible explanation for this neutral outcome is that PCI is overvalued in symptom relief and to some extent explained by placebo effects or transient non-cardiac causes of chest pain. However, the chosen exercise tolerance improvement may have been too optimistic in a population with good functional capacity. Also PCI was anatomic and not functional driven, and follow-up duration may have been to short to wear off the placebo effect. While the evidence is not sufficient to alter revascularization guidelines, the message of this 200-patient, high-quality study is potent and will reverberate throughout the cardiology community and warrants further study.

Predictors of Outcomes After Percutaneous Coronary Intervention in Older Patients Presenting With Non-ST-Elevation Acute Coronary Syndromes: Insights From the VCOR Registry

Background: The benefit of percutaneous coronary intervention (PCI) in elderly patients presenting with non-ST-elevation acute coronary syndromes (NSTEACS) is controversial. Identification of risk factors for major adverse events (MAE) after PCI may help to identify the cohort of older patients most likely to benefit from an invasive management strategy.

Management of Chronic Total Coronary Occlusion in Stable Ischemic Heart Disease by Percutaneous Coronary Intervention Versus Coronary Artery Bypass Grafting Versus Medical Therapy

Coronary chronic total occlusions (CTOs) are found in approximately 20% of angiograms. We sought to assess the variation in the management of patients with CTOs and to compare the clinical outcomes of CTO lesions with those of non-CTO lesions. We conducted a population-based cohort study and included all patients with stable angina who underwent cardiac catheterization from October 1, 2012, to June 30, 2013, in Ontario, Canada. The primary outcome was a composite of mortality and hospitalization for myocardial infarction. A total of 7,864 patients were included, of whom 2,279 (29%) had a CTO. There were substantial differences in revascularization rates for patients with CTOs across hospitals in Ontario (44.9% to 94.1%). Revascularization was associated with improved outcomes in the overall cohort. Although the advantage of coronary artery bypass grafting over medical therapy was consistent in both patients with CTOs and patients without CTOs, the benefit of percutaneous coronary intervention (PCI) was limited to patients without CTOs (hazard ratio 0.56, 95% confidence interval 0.40- to 0.78), with no difference in patients with CTOs. The CTO lesion, however, was revascularized in few of the PCI cases (41.1%), with PCI limited to the non-CTO lesion in most patients.