Concomitant Concomitant Coronary Artery Disease Research Articles

Pre-participation Withdrawal and Noncompletion of Cardiac Rehabilitation in Peripheral Artery Disease: MATCHED COMPARISONS TO CORONARY ARTERY DISEASE.

Despite the mortality benefit of cardiac rehabilitation (CR) participation, as well as its cost-effectiveness for people with peripheral artery disease (PAD), there are limited data on adherence and completion of CR in those with and without concomitant coronary artery disease (CAD). The objective of this study was to compare CR pre-participation withdrawal and noncompletion between patients with PAD and concomitant PAD and CAD (PAD/CAD) versus matched and unmatched patients with CAD (uCAD). Consecutively referred patients between 2006-2017 with PAD (n = 271) and PAD/CAD (n = 610) were matched to CAD by age, sex, diabetes, smoking status, and referral year. The uCAD (n = 14 487) group was included for comparison. Reasons for withdrawal were ascertained by interview. There were no significant differences in pre-participation withdrawal between PAD and matched CAD (46 vs 43%, P = .49), nor in noncompletion (22 vs 18%, P = .28). Results were similar for PAD/CAD and matched CAD (withdrawal: 36 vs 34%, P = .37) and (noncompletion: 25 vs 23%, P = .46). A smaller proportion of patients with uCAD withdrew (28%) than patients with PAD ( P < .001) and PAD/CAD ( P < .001), with no difference in noncompletion ( P > .40, both). There were no differences between PAD and PAD/CAD and their matched counterparts for medical and nonmedical reasons for withdrawal and noncompletion ( P ≥ .25, all). Pre-participation withdrawal rates were similar between patients with PAD, PAD/CAD, and their matched cohorts but greater than patients with uCAD. Once patients started CR, there were similar completion rates among all groups. Reports that patients with PAD are less likely to start CR may be related to their complex medical profile rather than PAD alone. Strategies to improve participation among patients with PAD should focus on the immediate post-referral period.

Risk of bleeding requiring blood transfusion after transcatheter implantation of the aortic valve in patients with concomitant coronary artery disease

Introduction. Perioperative bleeding is a potentially life-threatening complication of surgical intervention. The incidence of perioperative bleeding during transcatheter aortic valve implantation (TAVI) reaches 6%. An increased risk of perioperative bleeding is noted in patients requiring constant antiplatelet therapy, which includes patients with concomitant coronary artery disease (CAD).Aim. The study of risk factors of bleeding, which require blood transfusion in candidates for TAVI with concomitant CAD.Materials and methods. A retrospective study. The patients with concomitant CAD who underwent TAVI from 2016 to 2021 with hemodynamically significant coronary artery stenosis (n = 270) were included in this study. The incidence of early postoperative bleeding requiring blood transfusions was analyzed. Risk factors of bleeding development were evaluated.Results. The average age of the patients was 77.7 ± 7.2 years, the number of male and female patients was comparable (45.9 and 54.1%).The majority of patients were diagnosed with chronic heart failure (90.4%), more than half of the patients suffered from pulmonary hypertension (51.9%). The incidence of bleeding that required blood transfusion was 9.3%. The risk factors of the bleeding were dual antiplatelet therapy, baseline anemia (hemoglobin less than 120 g/l), history of stroke, chronic renal failure and critical aortic stenosis. The risk factors were included in the predictive model.Conclusion. Bleeding requiring blood transfusion in patients with severe aortic stenosis and CAD after TAVR occurs in 9.3%. It can be partially predicted using the predictive model. The using of the predictive model may be useful in determining the predominant risk of thrombotic or bleeding events after surgery.

Management of coronary artery disease in patients with aortic stenosis in the era of transcatheter aortic valve replacement.

Aortic stenosis (AS) is a common valve disorder among the elderly, and these patients frequently have concomitant coronary artery disease (CAD). Risk factors for calcific AS are similar to those for CAD. Historically, the treatment of these conditions involved simultaneous surgical replacement of the aortic valve (AV) with coronary artery bypass grafting. Since the advancement of transcatheter AV therapies, there have been tremendous advancements in the safety, efficacy, and feasibility of this procedure with expanding indications. This has led to a paradigm shift in our approach to the patient with AS and concomitant CAD. Data regarding the management of CAD in patients with AS are largely limited to single-center studies or retrospective analyses. This article aims to review available literature around the management of CAD in patients with AS and assist in the current understanding in approaches toward management.

Bilateral Minithoracotomy for Mitral Valve Repair and Coronary Bypass Grafting

Background Combined mitral valve and coronary artery surgery is usually accomplished via a median sternotomy and is associated with increased mortality and morbidity. Case Description We report on a 67-year-old patient with mitral valve regurgitation and concomitant coronary artery disease (CAD). The mitral valve was repaired using the loops and ring technique, and the left anterior descending artery was revascularized using the left internal mammary artery through a bilateral minithoracotomy approach. The postoperative course was uneventful. Conclusion Patients with mitral valve pathologies and concomitant CAD can be successfully operated via a bilateral minithoracotomy approach.

Association of Concomitant Coronary Artery Disease With Cardiovascular Events in Patients With Atrial Fibrillation - The Fushimi AF Registry.

Atrial fibrillation (AF) patients often have concomitant coronary artery disease (CAD); however, there are little data on clinical characteristics and outcomes of such patients in daily clinical practice in Japan.Methods and Results: The Fushimi AF Registry is a community-based prospective survey of AF patients in Fushimi-ku, Kyoto, Japan. Follow-up data were available for 4,464 patients, and the median follow up was 5.1 (interquartile range: 2.3-8.0) years. History of CAD was present in 647 patients (14%); of those patients, 267 (41%) had history of myocardial infarction (MI). Patients with CAD were older and had more comorbidities than those without CAD. The crude incidences (% per patient-year) of cardiovascular events were significantly higher in patients with CAD than those without CAD (cardiac death: 1.8 vs. 0.7, stroke or systemic embolism [SE]: 2.9 vs. 2.1, MI: 0.6 vs. 0.1, composite of those events: 5.1 vs. 2.8, respectively, all log-rank P<0.01). After multivariate adjustment, concomitant CAD was associated with incidence of cardiac events, and history of MI was associated with incidence of MI; however, neither history of CAD nor MI was associated with the incidence of stroke/SE. In Japanese AF patients, concomitant CAD was associated with higher prevalences of major co-morbidities and higher incidences of cardiovascular events; however, history of CAD was not associated with the incidence of stroke/SE.

Impact of extent of coronary artery disease and percutaneous revascularization assessed by the SYNTAX score on outcomes following transcatheter aortic valve replacement

ObjectivesThe aim of the study was to analyze the impact of concomitant coronary artery disease (CAD) assessed by the SYNTAX score (SS) and periprocedural percutaneous coronary intervention (PCI) on outcomes after transcatheter aortic valve replacement (TAVR).BackgroundDue to controversial data regarding the effect of CAD on outcomes after TAVR, proper revascularization strategies remain a matter of debate.Methods553 patients with severe aortic stenosis undergoing TAVR were included in this study. SS was calculated for each patient at baseline and after PCI. Primary outcome was one-year all-cause mortality.Results60.2% of patients (N = 333) exhibited CAD with a mean SS of 10.8 ± 8.8. Of those, 120 patients (36.0%) received periprocedural PCI. In the treatment group, mean SS was decreased from 14.9 ± 9.1 to 6.3 ± 6.7. Patients with concomitant CAD suffered more frequently from myocardial infarction (MI) post TAVR compared to those without CAD (2.1% vs. 0.0%; P < 0.01). In the CAD cohort, MI rates were comparable between patients with and without PCI (2.2% vs. 2.5%; P = 0.71). Regarding SS, patients with a residual SS < 8 showed significant lower rates of one-year mortality (9.0% vs. 18.2%; P = 0.016) and MACCE (16.5% vs. 32.2%; P = 0.001). Besides left bundle brunch, predictors for an increased one-year mortality were a residual SS ≥ 8 in the CAD group (OR = 3.17; P = 0.011) and a EuroSCORE ≥ 4% in the entire study population (OR = 2.18; P = 0.017).ConclusionOur results suggest that a residual SS-guided revascularization strategy may improve prognosis after TAVR in patients with concomitant CAD. PCI aiming for a residual SS < 8 was associated with improved one-year clinical outcomes.

USE OF HERBAL IMMUNOTROPIC MEDICINES FOR COMPLEX TREATMENT OF GENERALIZED PERIODONTITIS IN PATIENTS WITH CONCOMITANT CORONARY ARTERY DISEASE

The aim: Of this study was to improve the efficiency of complex medicamental treatment of generalized periodontitis (GP) in patients with concomitant CAD using of differentiated immunotropic therapy, especially herbal medicine «Immuno-ton». Material and methods: 130 patients with GP were observed (43 without and 81 with chronic CAD - stable angina, functional classes II-III (CCS)) with detection of oral hygiene indices for Green-Vermillion, inflammation of gums PMA, bleeding of gums PBI, depth of periodontal pockets (determined by direct method). The levels of TNF-α and sPECAM-1 in gingival fluid were detected by ELISA method. Results: The following article is dedicated to studying on the effectiveness of the proposed method of GP I and II degree of development treatment in patients with a concomitant coronary artery disease (CAD) using of herbal medicines with immunomodulating effect. The offered methods provide disappearance of clinical signs of inflammation in the periodontal tissues and prevention of inflammation recurrence in the long terms. Also, it was proved that usage of the forward method of the GP immunotropic therapy with including of herbal immunomodulators leads to normalization of dynamics of tumor necrosis factor -alfa (TNF-α) and soluble platelet-endothelial cell adhesion molecule -1 (sPECAM-1) in oral fluid of abovementioned contingent of patients. Conclusions: The progression of generalized periodontitis in patients with stable coronary heart disease is accompanied with manifestation of systemic inflammation, which have been reduced by immunomodulator Immuno-Ton and extratemporal gel with "Enterosgel" and herbal concentrate "Dzherelo".

Troponin T but not C-reactive protein is associated with myocardial mass and risk for, and time to future surgery for aortic stenosis; a population-based study

Abstract Objective High-sensitivity troponin T (hs-TnT) and high-sensitivity C-reactive protein (hs-CRP) may convey prognostic information in patients with aortic stenosis (AS). However, many association studies were cross-sectional, and the presence of myocardial hypertrophy and concomitant coronary artery disease (CAD) were usually not described. This study evaluated if hs-TnT and hs-CRP relate to myocardial mass, and associate with risk of and time to future surgery for AS in patients with and without concomitant CAD. Design In total, 336 patients who underwent surgery due to AS after participation in large population surveys were identified. Median age [interquartile range] was 59.8 [10.3] years at survey and 68.3 [12.7] years at surgery, and 48% were women. The median time between survey and surgery was 10.9 [9.3] years. Preoperatively, myocardial mass and the presence of CAD were assessed. Two matched referents were allocated for each case, and hs-TnT and hs-CRP were determined in stored plasma samples from the baseline survey. Uni- and multivariable conditional logistic regression analyses were used to estimate the risk (odds ratio [95% confidence interval]) related to one (ln) standard deviation increase in hs-TnT and hs-CRP. Time to surgery was evaluated by Kaplan-Mayer analysis and Cox regression. Results Hs-TnT was independently associated with surgery for AS in patients with concomitant CAD (odds ratio [95% confidence interval]) (1.22 [1.02–1.46]) and without concomitant CAD (1.39 [1.05–1.84]). Hs-CRP was not associated with surgery for AS after adjustment for traditional cardiovascular risk factors (1.06 [0.92–1.23]). Patients with high hs-TnT levels had shorter time to surgery compared those with low levels (Figure, p&amp;lt;0.001) whereas hs-CRP did not associate with time to surgery. Hs-TnT levels at survey associated independently with myocardial mass at surgery (p=0.002) but not with CAD and severity of stenosis. Conclusions Hs-TnT – but not hs-CRP – was associated with increased risk for, and shorter time to future surgery for AS. Hs-TnT associated with myocardial mass at surgery which indicates that Hs-TnT may be used as a clinical tool and allow for identification of patients with AS who could benefit from earlier intervention. Time to surgery; tertiles of hs-TnT Funding Acknowledgement Type of funding source: Foundation. Main funding source(s): The Swedish Heart–Lung Foundation

Effect of vorapaxar on cardiovascular and limb outcomes in patients with peripheral artery disease with and without coronary artery disease: Analysis from the TRA 2°P-TIMI 50 trial.

Intensive antithrombotic therapy reduces major adverse cardiovascular events (MACE) and major adverse limb events (MALE) in patients with peripheral artery disease (PAD). Recent studies have suggested heterogeneity in risk and benefit in those with and without concomitant coronary artery disease (CAD) and peripheral revascularization. We evaluated the risk of MACE and MALE in patients with PAD stratified by history of concomitant CAD and prior peripheral revascularization and whether the efficacy and safety of vorapaxar were similar in these subgroups. The TRA 2°P-TIMI 50 trial randomized 26,449 patients with prior MI, ischemic stroke, or PAD to vorapaxar or placebo. This analysis examined the effect of vorapaxar in a broad population of 6136 patients with PAD. Overall, vorapaxar significantly reduced MACE (HR 0.85, 95% CI 0.73, 0.99; p = 0.034) and MALE (HR 0.70, 95% CI 0.53, 0.92; p = 0.011) in patients with PAD. The absolute risk reduction (ARR) for MACE was greater in patients with PAD and CAD versus those with PAD alone (-2.2% vs 0.1%: number needed to treat (NNT) 45 vs 1000). Conversely, the ARR for MALE was higher in those with prior lower extremity revascularization (2.5% vs 0.2%: NNT 40 vs 500). Vorapaxar increased major bleeding (HR 1.39, 95% CI 1.12, 1.71; p = 0.003). The net clinical outcome in all patients with PAD was reduced with vorapaxar (HR 0.82, 95% CI 0.72, 0.94; p = 0.004), with benefits driven by reductions in MACE for those with CAD and by reductions in MALE for those with prior peripheral revascularization. Among patients with PAD, vorapaxar resulted in a net clinical benefit; however, the drivers of benefit were heterogeneous, with greater reductions in MACE in those with concomitant CAD and greater reductions in MALE in those with prior lower extremity revascularization, and unclear benefit in patients with neither. These clinical characteristics may be useful in identifying the subgroups of patients with PAD most likely to benefit from potent antithrombotic therapies. ClinicalTrials.gov Identifier: NCT00526474.

Hybrid Minimally Invasive Approach for Combined Obstructive Coronary Artery Disease and Severe Aortic Stenosis.

There is a high prevalence of concomitant coronary artery disease (CAD) and aortic stenosis (AS), and these conditions can be treated with a variety of invasive and/or percutaneous approaches. The aim of this study is to demonstrate the feasibility, efficacy, and safety of a staged transcatheter aortic valve replacement (TAVR) after a hybrid minimally invasive direct coronary artery bypass surgery (MIDCAB) to treat combined complex CAD and AS. Six patients with concomitant CAD and severe AS underwent staged treatment of their CAD with MIDCAB and TAVR. All patients had significant complex left main or left anterior descending artery (LAD) stenosis deemed to be not amenable to percutaneous coronary intervention (PCI). The average syntax score was 22±8 and the Society of Thoracic Surgeons score for surgical AVR was 8±3%. All patients underwent a single vessel MIDCAB for revascularization of the LAD (three patients required additional PCI for non-LAD disease). Two patients had pre-TAVR balloon aortic valvuloplasty and one patient also required treatment of severe mitral valve regurgitation with percutaneous edge-to-edge repair (the MitraClip). There was no intraprocedural or hospital mortality. No neurological deficits or vascular complications were recorded. A hybrid staged approach for combined complex CAD and severe AS with MIDCAB, PCI, and TAVR is a valid option in high-risk patients. The order and timing of these procedures must be tailored to the patient's clinical symptoms, stability, and severity of disease.

Arterial hypertension and diastolic blood pressure associate with aortic stenosis

Objectives. Due to age-related differences in aortic valve structure, it is likely that the pathophysiology of aortic stenosis (AS) and associated risk factors differ between age groups. Here we prospectively studied the influence of traditional cardiovascular risk factors on AS development requiring surgery among patients without concomitant coronary artery disease (CAD) and stratified for age. Design. This study included 322 patients, who had prior to surgery for AS participated in population-based surveys, and 131 of them had no visible CAD upon preoperative coronary angiogram. For each case, we selected four referents matched for age, gender, and geographic area. To identify predictors for surgery, we used multivariable conditional logistic regression with a model including arterial hypertension (or measured blood pressure and antihypertensive medication), cholesterol levels, diabetes, body mass index (BMI), and smoking. Results. In patients without CAD, future surgery for AS was associated with arterial hypertension and elevated levels of diastolic blood pressure in patients younger than 60 years at surgery (odds ratio [95% confidence interval]), (3.40 [1.45–7.93] and 1.60 [1.09–2.37], respectively), and with only impaired fasting glucose tolerance in patients 60 years or older at surgery (3.22 [1.19–8.76]). Conclusion. Arterial hypertension and elevated diastolic blood pressure are associated with a risk for AS requiring surgery in subjects below 60 years of age. Strict blood pressure control in this group is strongly advocated to avoid other cardiovascular diseases correlated to hypertension. If hypertension and elevated diastolic blood pressure are risk factors for developing AS requiring surgery need further investigations. Notably, elevated fasting glucose levels were related to AS requiring surgery in older adults without concomitant CAD.

The efficacy and safety of non-vitamin K antagonist oral anticoagulants in patients with atrial fibrillation and coronary artery disease: A meta-analysis of randomized trials.

Patients with atrial fibrillation and concomitant coronary artery disease (CAD) are at higher risk for myocardial infarction or cardiovascular death, often require antiplatelet therapy and are therefore exposed to an increased risk of bleeding. This meta-analysis aimed to compare the efficacy and safety profile of non-vitamin K antagonist oral anticoagulants (NOACs) with warfarin in patients with atrial fibrillation and concomitant CAD. We performed a trial-level meta-analysis of CAD subgroups from four trials of NOAC versus warfarin in patients with atrial fibrillation, comparing the primary trial endpoints (efficacy: stroke or systemic embolic event; safety: International Society on Thrombosis and Haemostasis major bleeding) in patients with versus those without CAD, and used interaction testing to assess for treatment effect modification. In total, 58,606 patients with established CAD were included in this meta-analysis. NOACs reduced the risk of stroke/systemic embolic event irrespective of presence of CAD (CAD: 0.76 (0.56-1.04); no CAD: hazard ratio 0.77 (0.56-1.06); p-INT 0.93). Similarly, there was no effect modification by presence of CAD for major bleeding (CAD: hazard ratio 0.92 (0.65-1.32), no CAD: 0.83 (0.61-1.12); p-INT 0.46) or myocardial infarction (CAD: hazard ratio 0.95 (0.62-1.44); no CAD: hazard ratio 0.95 (0.60-1.50); p-INT = 0.98). While NOACs reduced all-cause mortality in patients without CAD compared with warfarin (hazard ratio 0.85 (0.71-1.02)), there was no difference in mortality between NOACs and warfarin in the CAD group (hazard ratio 0.99 (0.82-1.20); p-INT 0.01). The present meta-analysis of four trials supports that NOACs are safe and at least as effective as warfarin in patients with atrial fibrillation and established CAD.

Effects of coronary artery disease in patients undergoing transcatheter aortic valve implantation: A study of age- and gender-matched cohorts

BackgroundThe prognostic role of concomitant coronary artery disease (CAD) among patients undergoing transcatheter aortic valve implantation (TAVI) is still uncertain. MethodsData from the Bern TAVI Registry and the Bern PCI Registry were analyzed. Patients with concomitant CAD undergoing TAVI (TAVI+CAD) were age- and gender-matched to the following two cohorts: patients without CAD undergoing TAVI (TAVI-noCAD) and patients with stable CAD undergoing percutaneous coronary intervention (CAD-noAS). Major adverse cardiovascular and cerebrovascular events (MACCE), defined as the composite of cardiovascular death, myocardial infarction, or cerebrovascular events, represented the primary endpoint at 1-year. ResultsOut of 9478 procedures performed between 2007 and 2013 (807 TAVI; 8671 PCI), three cohorts, each including 248 subjects, were derived. At 1-year, MACCE were significantly increased among TAVI+CAD compared with TAVI-noCAD (16.8% vs. 9.8%, hazard ratio, HR, 1.75, 95% confidence intervals, CI, 1.06–2.89, p=0.030) and CAD-noAS patients (16.8% vs. 9.5%, HR 1.85, 95%CI 1.11–3.09, p=0.018) whereas no difference was found between TAVI-noCAD and CAD-noAS patients. The higher rate of MACCE among TAVI+CAD patients was mainly driven by an increased risk of cardiovascular mortality compared with the TAVI-noCAD (HR 1.86, 95%CI 1.03–3.36, p=0.040) and CAD-noAS cohorts (HR 2.29, 95%CI 1.22–4.30, p=0.010). The 1-year rate of MACCE was similar between TAVI-noCAD and CAD-noAS patients (9.8% vs. 9.5%, HR 1.05, 95%CI 0.59–1.87, p=0.86). ConclusionsConcomitant CAD in the setting of TAVI conveyed an increased risk of ischemic events and cardiovascular mortality at 1-year follow-up.

Long-Term Comparative Outcomes of Patients With Peripheral Artery Disease With and Without Concomitant Coronary Artery Disease

There are limited contemporary data on guideline-directed medical therapy (GDMT) utilization and long-term clinical outcomes in patients with peripheral artery disease (PAD) with and without concomitant coronary artery disease (CAD). From 2006 to 2013, 879 patients with claudication or critical limb ischemia (CLI) underwent diagnostic angiography or therapeutic endovascular intervention at our multidisciplinary vascular center. GDMT use was assessed at the time of angiography, and major adverse cardiovascular and cerebrovascular events (MACCE) and all-cause mortality were determined during 5years of follow-up. Cox proportional hazard modeling was used to adjust for baseline differences between patients with and without concomitant CAD. Despite a higher adherence to GDMT (all p ≤0.002) for the use of aspirin, angiotensin-converting enzyme inhibitor/angiotensin receptor blocker, and statins, patients with PAD and concomitant CAD had higher unadjusted 5-year rates of MACCE (hazard ratio [HR] 1.7, 95% CI 1.3 to 2.1, p=0.0001) and all-cause mortality (HR 1.86, 95% CI 1.4 to 2.4, p= 0.0001). After adjustment for baseline co-morbidities, the presence of CAD remained an independent risk factor for mortality (adjusted HR 1.35, 95% CI 1.02 to 1.80, p= 0.04) but not for MACCE (adjusted HR 1.24, 95% CI 0.96 to 1.60, p= 0.10) in patients with PAD. A sensitivity analysis limited to patients with CLI demonstrated that concomitant CAD was associated with significantly higher adjusted rates of both MACCE (adjusted HR 1.52, 95% CI 1.14 to 2.03, p= 0.01) and mortality (adjusted HR 1.64, 95% CI 1.12 to 2.20, p= 0.006). In conclusion, despite higher rates of GDMT use, PAD patients with concomitant CAD had significantly increased risk of all-cause mortality during a 5-year postprocedural follow-up. The subgroup of CLI patients with concomitant CAD was at particularly high risk for both MACCE and all-cause mortality.

Fused cardiac hybrid imaging with coronary computed tomography angiography and positron emission tomography in patients with complex coronary artery anomalies.

To provide data on the value of fused cardiac hybrid imaging with coronary computed tomography angiography (CCTA) and positron emission tomography myocardial perfusion imaging (PET-MPI) in patients with complex coronary artery anomalies (CCAA). This is a retrospective, single-center study. Seven consecutive patients with CCAA (mean 57±7y, 86% were male) who underwent clinically indicated hybrid CCTA/PET-MPI between 2005 and 2015 in our clinic were included. The findings from both modalities and fused cardiac hybrid imaging were evaluated in these patients. Out of the seven patients with CCAA, two patients had Bland-White-Garland anomaly, two patients showed a coronary artery fistula, two patients showed a "single right," and one patient showed a "single left" coronary artery. Semiquantitative fused hybrid CCTA/PET-MPI depicted inferolateral scar matching the territory of a nonanomalous vessel with significant concomitant coronary artery disease (CAD) in one patient only. In contrast, analysis of quantitative myocardial blood flow (MBF) as assessed by fused hybrid CCTA/PET-MPI revealed abnormally reduced flow capacities in the territories subtended by the anomalous vessels in 4 patients. In this case series of middle-aged patients with CCAA, perfusion defects as assessed by semiquantitative PET-MPI were rare and attributable to concomitant CAD rather than to the anomalous vessel itself. By contrast, impaired MBF as assessed by quantitative hybrid CCTA/PET-MPI was revealed in the majority of patients in the vessel territories subtended by the anomalous coronary artery itself. Fused hybrid CCTA/PET-MPI incorporating information on morphology and on semiquantitative and quantitative myocardial perfusions may provide added value for the management of patients with CCAA.

A Systematic Review of Early Results Following Synchronous or Staged Carotid Artery Stenting and Coronary Artery Bypass Grafting.

Background The optimal management of patients with concomitant coronary artery disease (CAD) and severe carotid artery stenosis remains a controversy. We performed a systematic review of studies comparing early outcomes of synchronous or staged carotid artery stenting (CAS) and coronary artery bypass grafting (CABG) in the treatment of patients with concomitant CAD and severe carotid artery stenosis. Methods Multiple databases were systematically searched to identify studies of synchronous or staged CAS and CABG in the treatment of concomitant severe carotid and coronary artery disease published from 2005 to 2015. The quality of studies was assessed using the MINORS scale. The demographic data, risk factors, 30-day outcomes, and antiplatelet strategy were extracted. Results 23 studies were identified with a total of 873 and 459 patients in the staged and synchronous group, respectively. The observed overall death/stroke/MI rate was 8.5% (95% CI: 7.6-9.4%) in staged group and 4.8% (95% CI: 3.8-5.8%) in synchronous group. It seems that the synchronous group has better 30-day outcomes, but these data could not be compared statistically. Conclusion Our systematic review suggests either synchronous or staged CAS and CABG can be chosen for the treatment of concomitant carotid and coronary artery disease. It seems that the synchronous approach is relatively convenient and the antiplatelet strategy is relatively definite. For these patients, hybrid revascularization by synchronous CAS and CABG might be a feasible and promising therapeutic strategy. Our conclusions and the quality of the existing data suggest that a randomized controlled trial is needed to define the best treatment for patients with concomitant carotid and coronary artery disease.

Increased plant sterol deposition in vascular tissue characterizes patients with severe aortic stenosis and concomitant coronary artery disease

The aim of the study was to evaluate the relationship between phytosterols, oxyphytosterols, and other markers of cholesterol metabolism and concomitant coronary artery disease (CAD) in patients with severe aortic stenosis who were scheduled for elective aortic valve replacement.Markers of cholesterol metabolism (plant sterols and cholestanol as markers of cholesterol absorption and lathosterol as an indicator of cholesterol synthesis) and oxyphytosterols were determined in plasma and aortic valve tissue from 104 consecutive patients with severe aortic stenosis (n=68 statin treatment; n=36 no statin treatment) using gas chromatography-flame ionization and mass spectrometry. The extent of CAD was determined by coronary angiography prior to aortic valve replacement.Patients treated with statins were characterized by lower plasma cholesterol, cholestanol, and lathosterol concentrations. However, statin treatment did not affect the sterol concentrations in cardiovascular tissue. The ratio of campesterol-to-cholesterol was increased by 0.46±0.34μg/mg (26.0%) in plasma of patients with CAD. The absolute values for the cholesterol absorption markers sitosterol and campesterol were increased by 18.18±11.59ng/mg (38.8%) and 11.40±8.69ng/mg (30.4%) in the tissues from patients with documented CAD compared to those without concomitant CAD. Campesterol oxides were increased by 0.06±0.02ng/mg (17.1%) in the aortic valve cusps and oxidized sitosterol-to-cholesterol ratios were up-regulated by 0.35±0.2ng/mg (22.7%) in the plasma of patients with CAD. Of note, neither cholestanol nor the ratio of cholestanol-to-cholesterol was associated with CAD.Patients with concomitant CAD are characterized by increased deposition of plant sterols, but not cholestanol in aortic valve tissue. Moreover, patients with concomitant CAD were characterized by increased oxyphytosterol concentrations in plasma and aortic valve cusps.

Concurrent Coronary Artery and Valvular Heart Disease - Hybrid Treatment Strategies in 2013.

Concomitant coronary artery disease (CAD) and valvular heart disease is an increasingly common problem in the ageing population. Hybrid procedures combine surgical and transcatheter approaches to facilitate minimally invasive surgery or to transform a single high-risk open surgery into two less risky procedures. In ideal circumstances, this strategy may decrease the surgical risk in elderly, high-risk and reoperative surgical candidates, while improving patient comfort, convenience and cost-effectiveness. Hybrid procedures can be performed in a staged fashion or as a 'one-stop' procedure in a hybrid operating suite. Increasing evidence supports the safety and short-term efficacy of hybrid valve repair or replacement and coronary revascularisation procedures. Nevertheless, important questions remain, including the optimal timing of the individual procedures and the optimal antiplatelet therapy after percutaneous coronary intervention. With ongoing advances in procedural techniques and anticoagulation strategies, as well as the accumulation of long-term outcomes data, hybrid approaches to concomitant CAD and valvular heart disease will likely become increasingly common.

Transcatheter aortic valve implantation in patients with and without concomitant coronary artery disease: comparison of characteristics and early outcome in the German multicenter TAVI registry

To examine the prevalence and impact of concomitant coronary artery disease (CAD) on short-term outcome after transcatheter aortic valve implantation (TAVI). The prevalence of CAD in patients undergoing surgical aortic valve replacement is estimated at 30-50 % and its presence increases procedural risk. The prevalence and impact of CAD on outcome after TAVI are not well defined. We analyzed 1,382 patients enrolled in the German TAVI registry; the majority (81 %) received the Medtronic CoreValve. The presence of coronary lesions with ≥50 % stenosis on pre-TAVI angiography defined the existence of concomitant CAD. 859 patients (62.2 %) had concomitant CAD, of which 534 (62.3 %) had multi-vessel and 83 (9.7 %) left main disease. Patients with CAD were younger (81.5 ± 6.1 vs. 82.1 ± 6.3 years, p < 0.05), more commonly males (49.4 vs. 30.0 %, p < 0.0001) and diabetics (36.9 vs. 31.2 %, p < 0.05), and had a worse Canadian Cardiovascular Society angina class at baseline compared to patients with no CAD. During TAVI patients with CAD more often required additional coronary intervention and had longer procedures, but procedural success rates were similar (97.1 vs. 97.7 %). Crude in-hospital mortality was higher in patients with CAD (10.0 vs. 5.5 %, OR 1.90, 95 % CI 1.23-2.93), but this was not significant after adjustment for confounders (adjusted OR 1.41, 95 % CI 0.85-2.33). Both groups had significant improvement in 30-day symptoms and quality of life. The prevalence of CAD in contemporary TAVI patients is high. Its presence characterizes a high-risk population and is associated with increased crude short-term mortality, largely explained by co-morbidities, but does not limit functional improvement after TAVI.

Abstract 425: Coronary Artery Disease in Patients with Premature Atherosclerotic Peripheral Artery Disease

Objective: Premature atherosclerotic peripheral artery disease (PAD) is being diagnosed with increasing frequency. Little is known about concomitant coronary artery disease (CAD) in patients with premature PAD. This study examines prevalence, associated clinical characteristics, and predictors of concomitant CAD in young PAD patients. Methods: We studied patients with severe atherosclerotic PAD &lt;55 years of age (mean 49.36±6.45 yrs) treated at a single academic Vascular center between 1998 and 2010. Data was collected at the time of initial evaluation. CAD was defined by documented acute coronary syndrome; and/or prior coronary revascularizations. Associations with concomitant CAD were evaluated univariately using chi-square tests for categorical characteristics or t-tests for continuous characteristics, and using multivariable logistic regression. Results: Total of 561 patients (46% female, 20% Black) were analyzed. Mean age at diagnosis was 46.64±6.86 years. Risk factors included smoking (97%), hyperlipidemia (67%), hypertension (64%), family history of premature CAD (47%), and diabetes (25%). Aortoiliac disease was present in 77% of patients; 36% were disabled. Overall, 174 (31%) patients had clinical CAD. Patients with premature CAD were less likely to be Blacks (p=0.004), had greater frequency of hypertension, hyperlipidemia, diabetes, family history of premature CAD, polyvascular disease (i.e. cerebral vascular disease [CeVD]) (p&lt;.001 for each), renovascular disease (p=.016) and mesenteric disease (p=.012). Multivariable logistic regression modeling showed higher odds of concomitant CAD for patients with hyperlipidemia (OR 4.71; 95 CI 2.82-7.85; p&lt;.0001), diabetes (OR 2.11; 95% CI 1.28-3.47; p&lt;0.01), family history of premature CAD OR 2.00; 95% CI 1.27-3.14;p&lt;0.01) CeVD (OR 2.15; 95% CI 1.34-3.48;p&lt;0.01), mesenteric vascular disease (OR 2.70;95% CI 1.19-6.14; p=.02). One pack year in smoking increase had 1.01 times odds of concomitant CAD (95% CI 1.001-1.018; p=.02). Conclusions: Clinical CAD was prevalent in 1/3 of patients with premature PAD, and those with premature CAD were less likely to be Black. Among patients with premature PAD, higher odds of concomitant clinical CAD were associated with presence of hyperlipidemia, diabetes, family history of premature CAD, polyvascular disease.