Coronary Revascularization Therapy Research Articles

Percutaneous coronary revascularization versus medical therapy in chronic coronary syndromes: An updated meta-analysis of randomized controlled trials.

Coronary artery disease (CAD) is a main cause of morbidity and mortality. The effectiveness of coronary revascularization in chronic coronary syndromes (CCS) is still debated. Our recent study showed the superiority of coronary revascularization over optimal medical therapy (OMT) in reducing cardiovascular (CV) mortality and myocardial infarction (MI). The recent publication of the ORBITA-2 trial suggested superiority of percutaneous coronary revascularization (PCI) in reducing angina and improving quality of life. Therefore, we aimed to provide an updated meta-analysis evaluating the impact of PCI on both clinical outcomes and angina in CCS. Relevant studies were screened in PubMed/Medline until 08/01/2024. Randomized controlled trials (RCTs) comparing PCI to OMT in CCS were selected. The primary outcome was CV death. Secondary outcomes were MI, all-cause mortality, stroke, major bleeding and angina severity. Nineteen RCTs involving 8616 patients were included. Median follow-up duration was 3.3 years. Revascularization significantly reduced CV death (4.2% vs. 5.5%; OR = .77; 95% CI .62-.96, p = .02). Subgroup analyses favoured revascularization in patients without chronic total occlusions (CTOs) (p = .052) and those aged <65 years (p = .02). Finally, a follow-up duration beyond 3 years showed increased benefit of coronary revascularization (p = .04). Secondary outcomes analyses showed no significant differences, except for a lower angina severity in the revascularization group according to the Seattle Angina Questionnaire (SAQ) (p = .04) and to the Canadian Cardiovascular Society (CCS) classification (p = .005). PCI compared to OMT significantly reduces CV mortality and angina severity, improving quality of life in CCS patients. This benefit was larger without CTOs, in patients aged <65 years and with follow-up duration beyond 3 years.

Intentional coronary revascularization versus conservative therapy in patients after peripheral artery revascularization due to critical limb ischemia: the INCORPORATE trial.

INCORPORATE trial was designed to evaluate whether default coronary-angiography (CA) and ischemia-targeted revascularization is superior compared to a conservative approach for patients with treated critical limb ischemia (CLI). Registered at clinicaltrials.gov (NCT03712644) on October 19, 2018. Severe peripheral artery disease is associated with increased cardiovascular risk and poor outcomes. INCORPORATE was an open-label, prospective 1:1 randomized multicentric trial that recruited patients who had undergone successful CLI treatment. Patients were randomized to either a conservative or invasive approach regarding potential coronary artery disease (CAD). The conservative group received optimal medical therapy alone, while the invasive group had routine CA and fractional flow reserve-guided revascularization. The primary endpoint was myocardial infarction (MI) and 12-month mortality. Due to COVID-19 pandemic burdens, recruitment was halted prematurely. One hundred eighty-five patients were enrolled. Baseline cardiac symptoms were scarce with 92% being asymptomatic. Eighty-nine patients were randomized to the invasive approach of whom 73 underwent CA. Thirty-four percent had functional single-vessel disease, 26% had functional multi-vessel disease, and 90% achieved complete revascularization. Conservative and invasive groups had similar incidences of death and MI at 1year (11% vs 10%; hazard ratio 1.21 [0.49-2.98]). Major adverse cardiac and cerebrovascular events (MACCE) trended for hazard in the Conservative group (20 vs 10%; hazard ratio 1.94 [0.90-4.19]). In the per-protocol analysis, the primary endpoint remained insignificantly different (11% vs 7%; hazard ratio 2.01 [0.72-5.57]), but the conservative approach had a higher MACCE risk (20% vs 7%; hazard ratio 2.88 [1.24-6.68]). This trial found no significant difference in the primary endpoint but observed a trend of higher MACCE in the conservative arm.

The predictive and prognostic value of risk factors in patients receiving hybrid coronary revascularization with postoperative pulmonary complications.

The mortality rate of coronary artery disease ranks first in developed countries, and coronary revascularization therapy is an important cornerstone of its treatment. The postoperative pulmonary complications (PPCs) in patients receiving one-stop hybrid coronary revascularization (HCR) aggravate the dysfunction of multiple organs such as the heart and lungs, therefore increasing mortality. However, the risk factors are still unclear. The objective of this study was to explore the risk factors of PPCs after HCR surgery. In this study, the perioperative data of 311 patients undergoing HCR surgery were reviewed. All patients were divided into two groups according to whether the PPCs occurred. The baseline information and surgery-related indicators in preoperative laboratory examination, intraoperative fluid management, and anesthesia management were compared between the two groups. Advanced age [odds ratio (OR): 1.065, 95% confidence interval (CI): 1.030-1.101, P<0.001], high body mass index (BMI; OR: 1.113, 95% CI: 1.011-1.225, P=0.02), history of percutaneous coronary intervention (PCI) surgery (OR: 2.831, 95% CI: 1.388-5.775, P=0.004), one-lung volume ventilation (OR: 3.804, 95% CI: 1.923-7.526, P<0.001), inhalation of high concentration oxygen (OR: 3.666, 95% CI: 1.719-7.815, P=0.001), the application of positive end-expiratory pressure (PEEP; OR: 2.567, 95% CI: 1.338-4.926, P=0.005), and long one-lung ventilation time (OR: 1.015, 95% CI: 1.006-1.023, P=0.001) may be risk factors for postoperative PPCs in patients undergoing one-stop coronary revascularization surgery. Using the above seven factors to jointly predict the risk of PPCs in patients undergoing one-stop coronary revascularization surgery, the receiver operating characteristic (ROC) curve showed an area under the curve (AUC) =0.873, 95% CI: 0.835-0.911, sensitivity: 84.81%, and specificity: 75.82%; the predictive model was shown to be effective. Patients undergoing HCR surgery with advanced age, high BMI, a history of PCI surgery, one-lung volume ventilation, inhalation of high concentration oxygen, use of PEEP, and prolonged single lung ventilation are more prone to PPCs.

Impact of atherosclerosis imaging-quantitative computed tomography on diagnostic certainty, downstream testing, coronary revascularization, and medical therapy: the CERTAIN study.

The incremental impact of atherosclerosis imaging-quantitative computed tomography (AI-QCT) on diagnostic certainty and downstream patient management is not yet known. The aim of this study was to compare the clinical utility of the routine implementation of AI-QCT versus conventional visual coronary CT angiography (CCTA) interpretation. In this multi-centre cross-over study in 5 expert CCTA sites, 750 consecutive adult patients referred for CCTA were prospectively recruited. Blinded to the AI-QCT analysis, site physicians established patient diagnoses and plans for downstream non-invasive testing, coronary intervention, and medication management based on the conventional site assessment. Next, physicians were asked to repeat their assessments based upon AI-QCT results. The included patients had an age of 63.8 ± 12.2 years; 433 (57.7%) were male. Compared with the conventional site CCTA evaluation, AI-QCT analysis improved physician's confidence two- to five-fold at every step of the care pathway and was associated with change in diagnosis or management in the majority of patients (428; 57.1%; P < 0.001), including for measures such as Coronary Artery Disease-Reporting and Data System (CAD-RADS) (295; 39.3%; P < 0.001) and plaque burden (197; 26.3%; P < 0.001). After AI-QCT including ischaemia assessment, the need for downstream non-invasive and invasive testing was reduced by 37.1% (P < 0.001), compared with the conventional site CCTA evaluation. Incremental to the site CCTA evaluation alone, AI-QCT resulted in statin initiation/increase an aspirin initiation in an additional 28.1% (P < 0.001) and 23.0% (P < 0.001) of patients, respectively. The use of AI-QCT improves diagnostic certainty and may result in reduced downstream need for non-invasive testing and increased rates of preventive medical therapy.

Preventive Strategies for Perioperative Ischemic Heart Disease during Carotid Artery Stenting.

We have been performing preoperative coronary artery assessments and implementing coronary revascularization or intraoperative adjunctive therapies as needed in patients scheduled for carotid artery stenting (CAS) to prevent ischemic heart disease. In this study, we report the results of a retrospective observation of patients who underwent CAS under our treatment strategy to prevent perioperative coronary ischemic complications. A total of 224 cases from January 2014 to December 2021 were included. Following preoperative coronary artery CTA, preoperative coronary artery treatment or intraoperative adjunctive therapy (temporary transcutaneous cardiac pacemaker [TTCP] or intra-aortic balloon pumping [IABP]) was performed based on the degree of stenosis. We analyzed the outcomes of patients treated with CAS under this strategy at our institution. Coronary artery disease was detected preoperatively in 143 cases (64%), with 91 cases (41%) indicated for coronary revascularization. Preoperative coronary artery treatment was performed in 76 cases (34%) prior to CAS, and adjunctive therapy with TTCP or IABP was provided in 28 cases (13%) during the procedure. No case developed perioperative coronary ischemic complication. In patients who have undergone CAS, perioperative coronary ischemic complications might be reduced by evaluating the risk of ischemic heart disease preoperatively, performing pre-CAS coronary artery intervention based on the severity of the lesions, and administering intraoperative adjunctive therapy.

Outcomes of coronary revascularization vs. optimal medical therapy alone for ischemic left ventricular dysfunction: A meta-analysis of randomized controlled trials.

Outcomes of coronary revascularization vs. optimal medical therapy alone for ischemic left ventricular dysfunction: A meta-analysis of randomized controlled trials.

Screening and Management of Coronary Artery Disease in Kidney Transplant Candidates.

Cardiovascular disease (CVD) is a major cause of morbidity and mortality in patients with chronic kidney disease (CKD), especially in end-stage renal disease (ESRD) patients and during the first year after transplantation. For these reasons, and due to the shortage of organs available for transplant, it is of utmost importance to identify patients with a good life expectancy after transplant and minimize the transplant peri-operative risk. Various conditions, such as severe pulmonary diseases, recent myocardial infarction or stroke, and severe aorto-iliac atherosclerosis, need to be ruled out before adding a patient to the transplant waiting list. The effectiveness of systematic coronary artery disease (CAD) treatment before kidney transplant is still debated, and there is no universal screening protocol, not to mention that a nontailored screening could lead to unnecessary invasive procedures and delay or exclude some patients from transplantation. Despite the different clinical guidelines on CAD screening in kidney transplant candidates that exist, up to today, there is no worldwide universal protocol. This review summarizes the key points of cardiovascular risk assessment in renal transplant candidates and faces the role of noninvasive cardiovascular imaging tools and the impact of coronary revascularization versus best medical therapy before kidney transplant on a patient's cardiovascular outcome.

Effects of Elective Coronary Revascularization vs Medical Therapy Alone on Noncardiac Mortality: A Meta-Analysis

BackgroundUncertainty exists whether coronary revascularization plus medical therapy (MT) is associated with an increase in noncardiac mortality in chronic coronary syndrome (CCS) when compared with MT alone, particularly following recent data from the ISCHEMIA-EXTEND (International Study of Comparative Health Effectiveness with Medical and Invasive Approaches) trial. ObjectivesThis study conducted a large-scale meta-analysis of trials comparing elective coronary revascularization plus MT vs MT alone in patients with CCS to determine whether revascularization has a differential impact on noncardiac mortality at the longest follow-up. MethodsWe searched for randomized trials comparing revascularization plus MT vs MT alone in patients with CCS. Treatment effects were measured by rate ratios (RRs) with 95% CIs, using random-effects models. Noncardiac mortality was the prespecified endpoint. The study is registered with PROSPERO (CRD42022380664). ResultsEighteen trials were included involving 16,908 patients randomized to either revascularization plus MT (n = 8,665) or to MT alone (n = 8,243). No significant differences were detected in noncardiac mortality between the assigned treatment groups (RR: 1.09; 95% CI: 0.94-1.26; P = 0.26), with absent heterogeneity (I2 = 0%). Results were consistent without the ISCHEMIA trial (RR: 1.00; 95% CI: 0.84-1.18; P = 0.97). By meta-regression, follow-up duration did not affect noncardiac death rates with revascularization plus MT vs MT alone (P = 0.52). Trial sequential analysis confirmed the reliability of meta-analysis, with the cumulative Z-curve of trial evidence within the nonsignificance area and reaching futility boundaries. Bayesian meta-analysis findings were consistent with the standard approach (RR: 1.08; 95% credible interval: 0.90-1.31). ConclusionsIn patients with CCS, noncardiac mortality in late follow-up was similar for revascularization plus MT compared with MT alone.

Heart-Brain Team Approach of Acute Myocardial Infarction Complicating Acute Stroke: Characteristics of Guideline-Recommended Coronary Revascularization and Antithrombotic Therapy and Cardiovascular and Bleeding Outcomes.

Background Acute myocardial infarction (AMI) infrequently occurs after acute stroke. The Heart-brain team approach has a potential to appropriately manage this poststroke cardiovascular complication. However, clinical outcomes of AMI complicating acute stroke (AMI-CAS) with the heart-brain team approach have not been characterized. The current study investigated cardiovascular outcomes in patients with AMI-CAS managed by a heart-brain team. Methods and Results We retrospectively analyzed 2390 patients with AMI at our institute (January 1, 2007-September 30, 2020). AMI-CAS was defined as the occurrence of AMI within 14 days after acute stroke. Major adverse cerebral/cardiovascular events (cardiac-cause death, nonfatal myocardial infarction, and nonfatal stroke) and major bleeding events were compared in subjects with AMI-CAS and those without acute stroke. AMI-CAS was identified in 1.6% of the subjects. Most AMI-CASs (37/39=94.9%) presented ischemic stroke. Median duration of AMI from the onset of acute stroke was 2 days. Patients with AMI-CAS less frequently received primary percutaneous coronary intervention (43.6% versus 84.7%; P<0.001) and dual-antiplatelet therapy (38.5% versus 85.7%; P<0.001), and 33.3% of them did not receive any antithrombotic agents (versus 1.3%; P<0.001). During the observational period (median, 2.4 years [interquartile range, 1.1-4.4 years]), patients with AMI-CAS exhibited a greater likelihood of experiencing major adverse cerebral/cardiovascular events (hazard ratio [HR], 3.47 [95% CI, 1.99-6.05]; P<0.001) and major bleeding events (HR, 3.30 [95% CI, 1.34-8.10]; P=0.009). These relationships still existed even after adjusting for clinical characteristics and medication use (major adverse cerebral/cardiovascular event: HR, 1.87 [95% CI, 1.02-3.42]; P=0.04; major bleeding: HR, 2.67 [95% CI, 1.03-6.93]; P=0.04). Conclusions Under the heart-brain team approach, AMI-CAS was still a challenging disease, reflected by less adoption of primary percutaneous coronary intervention and antithrombotic therapies, with substantially elevated cardiovascular and major bleeding risks. Our findings underscore the need for a further refined approach to mitigate their ischemic/bleeding risks.

Successful conservative management of left ventricular assist device candidates.

Clinical trials comparing LVADs vs. conservative therapy were performed before the availability of novel medications or used suboptimal medical therapy. This study aimed to report that long-term stabilization of patients entering a left ventricular assist device (LVAD) programme is possible with the use of aggressive conservative therapy. This is important because the excellent clinical stabilization provided by LVADs comes at the expense of significant complications. This study was a single-centre prospective evaluation of consecutive patients with advanced heart failure (HF) fulfilling criteria for LVAD implantation based on clinical and echocardiographic characteristics, cardiopulmonary exercise test, and right heart catheterization results. Their initial therapy included inotropes, thiamine, beta-blockers, digoxin, spironolactone, hydralazine, and nitrates followed by the introduction of novel HF therapies. Coronary revascularization and cardiac resynchronization therapy were performed when indicated, and all patients were closely followed at our outpatient clinic. During the study period, 28 patients were considered suitable for LVAD implantation (mean age 63±10.8years, 92% men, 78% ischaemic, median HF duration 4years). Clinical stabilization was achieved and maintained in 21 patients (median follow-up 20months, range 9-38months). Compared with baseline evaluation, cardiac index increased from 2.05 (1.73-2.28) to 2.88 (2.63-3.55) L/min/m2 , left ventricular end-diastolic diameter decreased from 65.5 (62.4-66) to 58.3 (53.8-62.5) mm, and maximal oxygen consumption increased from 10.1 (9.2-11.3) to 16.1 (15.3-19) mL/kg/min. Three patients died and only four ultimately required LVAD implantation. Notwithstanding the small size of our cohort, our results suggest that LVAD implantation could be safely deferred in the majority of LVAD candidates.

WELLENS SYNDROME - REPORT OF TWO CASES IN A PATIENT WITH MULTIVESSEL CORONARY ARTERY DISEASE

Acute coronary syndrome is a leading cause of death and increased morbidity in developed countries.Wellens syndrome as a high-risk of acute coronary syndrome is characterized by changes in the ST-T segment in theprecordial leads, indicating critical stenosis of the left anterior descending artery (LAD). This syndrome belongs tothe subgroup of patients with unstable angina pectoris who have inverted T waves in the anterior precordial leads onthe electrocardiogram (ECG). In our paper, we presented two cases of Wellens syndrome with critical LAD stenosis,performed coronary angiography and LAD stent placement. Wellens' syndrome can be a marker of critical LADstenosis in both its proximal and midsection. Changes can be temporary, last for months or disappear afterrevascularization treatment. Coronary angiography of the patient may also reveal critical stenosis of RCA (80%),LCx (100%), and diagonal-1 (90%). Failure to recognize this syndrome can cause a delay in referring patients forurgent coronary angiography and revascularization therapy that can lead to anterior myocardial infarction,significant left ventricular dysfunction, and even death. About 75% of patients with Wellens syndrome treated withconservative management alone will develop an extensive anterior myocardial infarction within a few days, with anaverage of 8.5 days from the onset of symptoms. This case study concludes that clinicians should be aware of ECGchanges in Wellens syndrome, which may occur during the pain-free period. For the definitive management ofWellens syndrome, the treatment of choice is cardiac catheterization with percutaneous coronary intervention (PCI),to relieve the patient of the symptoms of Wellens syndrome, as well as a number of complications of this acutecondition.

TCTAP C-168 Structural Interventional Solution When Coronary Revascularization and Optimal Medical Therapy Are Not Enough

TCTAP C-168 Structural Interventional Solution When Coronary Revascularization and Optimal Medical Therapy Are Not Enough

Left atrial function assessed by 3-dimensional echocardiography is an independent predictor for mortality in heart failure with reduced ejection fraction

Abstract Funding Acknowledgements Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Grant TE 137/2020 Background. Patients with heart failure and reduced ejection fraction (HFrEF) are at high risk for death. So far, left ventricular ejection fraction (LVEF) measured by 2-dimensional echocardiography (2DE) has been considered the main predictor of mortality in HFrEF. However, there are new echo parameters reflecting cardiac remodeling, assessed by 3-dimensional echocardiography (3DE), that might improve risk stratification in HFrEF. Aim. To assess comparative prognostic value of left heart function and remodeling parameters, measured by 2DE versus 3DE, in patients with HFrEF. Methods. 142 consecutive patients (60 ± 17 years, 91 males), diagnosed with HFrEF, in sinus rhythm, were assessed by 2DE, using dedicated views for the LV and left atrium (LA), and by 3DE, with full-volume multi-beat acquisitions of the LV and LA. Left ventricular volumes (LVVs) were measured from 2DE views, using the modified Simpson biplane method, and from 3DE using dedicated software. Maximal and minimal indexed LAVs were measured from 2DE, using the biplane area-length formula (2D_LAVmax and 2D_LAVmin); and from 3DE, using dedicated software package (3D_LAVmax and 3D_LAVmin). Patients were followed for 5 years (57 ± 11 months) after the index event. Primary outcome was mortality. Secondary outcomes were a composite endpoint (CE) of death and hospitalization for heart failure (HHF); HHF; and a composite cardiac events end-point (MACE) of death, HHF, myocardial infarction, coronary revascularization, arrhythmias, or cardiac resynchronization therapy. Results. At 5 years we recorded 52 deaths, 70 CE, 36 HHF, and 73 MACE. At baseline, mean 2DE and 3DE LVEFs were 32 ± 10% and 32 ± 9%, respectively. There was no significant difference between the LVVs or LVEF by 2DE or 3DE between survivors and non-survivors. However, there was a significant difference for total and indexed 2D_LAVmax, 3D_LAVmax, and 3D_LAVmin (Table 1) between survivors and non-survivors. Similarly, there was no significant correlations with endpoints for the 2DE or 3DE LVVs. However, total and indexed 2D_LAVmax correlated with death, CE, HFH, and MACE, all with P &amp;lt; 0.03. Furthermore, total and indexed 3D_LAVmax, and 3D_LAVmin correlated with death, CE, HFH, and MACE, all with P &amp;lt; 0.05. In a linear multivariate regression model, that included 2DE and 3DE LVEF, indexed 2D and 3D LAV max and min, only indexed 3D_LAVmin was an independent predictor for death (p &amp;lt; 0.001), CE (p = 0.005), HFH (p = 0.009) and MACE (p = 0.006). Furthermore, by ROC analysis, an indexed LAV of 30 ml/m2 by 3DE was able to predict death ( Sb 94%, Sp 80%, AUC 0.70), CE (Sb 98%, Sp 80%, AUC 0.67), HFH (Sb 96%, Sp 80%, 0.67), and MACE (Sb 93%, Sp 76%, AUC 0.66). Conclusion. LVEF by 2DE and 3DE, while smaller in non-survivors, was unable to predict death in a small cohort of patients with HFrEF. However, LAVs, particularly by 3DE, were able to predict cardiac events, suggesting the potential key value of evolving cardiac substrate. Abstract Table 1

Regional wall motion abnormalities predict culprit lesions in patients presenting with acute chest pain

Abstract Background Current ESC guidelines for non-ST-segment elevation myocardial infarction suggest the utilization of echocardiography in patients with inconclusive initial electrocardiography and cardiac enzymes. Besides detection of alternative pathologies associated with chest pain, echocardiography can screen for wall motion abnormalities (WMA) as sign of myocardial necrosis. Purpose We evaluated the ability of the assessment of regional WMA, detected via transthoracic echocardiography, to predict the presence of culprit lesions in patients presenting with acute chest pain to the emergency department. Methods In this prospective single-centre observational cohort study, we included consecutive patients presenting to the emergency department of our University Hospital with acute chest pain, suggestive of an acute coronary syndrome, between December 2018 and August 2020. Patients with ST-elevation myocardial infarction, hemodynamic instability, or known coronary artery disease were excluded. As part of initial workup, patients received bedside echocardiography for the assessment of regional WMA by a dedicated study physician, blinded to all patients' characteristics. The primary endpoint was defined as the presence of culprit lesions as detected in subsequent invasive coronary angiography, requiring coronary revascularization therapy. Logistic regression analysis was performed in different models adjusted for traditional cardiovascular risk factors, cardiac biomarkers as well as established risk scores. Area under the receiver operating characteristics curve (AUC) was calculated to assess a potential improvement in the prediction of culprit lesions. Results Overall, 657 patients (age 58.06±18.04 years, 53% male) were included in our study. WMA were detected in 76 patients (11.6%). Patients with WMA were older (66.92±13.85 vs. 56.90±18.21 years, p&amp;lt;0.001), had significantly higher Troponin-levels (18.5 [6.0; 91.5] vs. 6.0 [6.0; 15.0], p&amp;lt;0.001) and higher blood pressure (139.0±19.29 vs. 135.1±19.21, p=0.04). WMA were significantly more frequent in patients reaching the primary endpoint (26.2% vs. 7.6%, p&amp;lt;0.001). In multivariable regression analysis, the presence of WMA was associated with 3-fold increased odds of the presence of culprit lesions (3.41 [1.99–5.86], p&amp;lt;0.001). Adding WMA to a multivariable model containing the TIMI risk score, cardiac biomarkers and traditional risk factors significantly improved the AUC for prediction of obstructive coronary artery disease (0.777 to 0.804, p=0.009). Conclusion WMA strongly and independently predict the presence of culprit lesions in patients presenting with acute chest pain to the emergency department. Our results suggest that routine bedside echocardiography for assessment of WMA in emergency department may improve diagnostic algorithms in suspected acute coronary syndrome. Funding Acknowledgement Type of funding sources: None.

Discussion

Presenter: Dr Satoshi Kainuma Dr Robert E. Michler (New York, NY). Dr Kainuma, the American Association for Thoracic Surgery selection committee made an excellent decision in selecting your abstract for oral presentation. The topic is provocative in answering the question of whether multiple percutaneous coronary intervention (PCI) negatively influences clinical outcomes for ischemic mitral regurgitation, and your work could change clinical practice. Now, with the opportunity to carefully review your manuscript, it appears that an answer is close, but not yet definitive. The unifying aspect of the 2 comparison populations that you studied is that they both underwent restrictive annuloplasty for ischemic mitral regurgitation. Apart from this fact, the 2 groups were in fact very different. An operation such as coronary artery bypass grafting (CABG) is a major predictor of survival as is left ventricular ejection fraction. CABG was performed in significantly different numbers in each comparison group, 85% of 211 in the group with one or fewer PCIs, versus 47% of the 98 patients in the group with multiple PCIs. This fact alone may have led to differences in the outcomes measured and served as the primary driver of why the multiple PCI group did less well, in comparison to the single or no PCI group. Moreover, each additional operation performed would likely have influenced the outcomes measured. Because the multiple PCI group included 50% fewer total patients, the influence of these additional procedures may have negatively influenced the results for the group. And, another cofounding variable such as surgical ventricular reconstruction, which is a highly technical and demanding operation, with its own morbidity and mortality, was performed in 61 of the 211 patients with no or 1 PCI and 35 of the 98 patients with multiple PCIs. Was CABG required less frequently in the multiple PCI group because PCI was so successful in reperfusion of the at-risk territory or because the coronary anatomy was inherently bad? Or worse yet, perhaps the PCI—the prior PCI—had inflamed, sclerosed, and narrowed the distal vessel, making it ungraftable in the eyes of the surgeon? Dr Satoshi Kainuma (Suita, Osaka, Japan). Thank you, Professor Michler, for your great comments and important question. I think both are the reasons why patients with multiple PCI groups were not amenable to CABG. I mean that they were more likely to have more severe disease of the vessel, so bypass surgery was difficult. In addition to that, the result of the PCI was excellent for some patients, whereas not in others. So, I guess both factors were the reasons to explain the infrequent rates of concomitant bypass surgery for patients with multiple PCIs. Dr Michler. Was ischemic mitral regurgitation present at the time of the original PCI? And if it was, was the decision to perform a restrictive annuloplasty made because the desire was to avoid bypass surgery or was the belief that it might in and of itself reduce the grade of ischemic mitral regurgitation? Dr Kainuma. Thank you for your great question. Unfortunately, every patient was not evaluated in terms of ischemic mitral regurgitation at the time of the PCI. This is a problem. And secondly, interventionists in Japan are quite aggressive and prefer to do PCI whenever they see the ischemic mitral regurgitation. Probably because they do not consider that CABG is the best coronary revascularization therapy for patients with ischemic mitral regurgitation and myocardial dysfunction. So, Japanese cardiologists and interventionists are well trained in terms of the procedural aspect, but not with patient selection or indication for the PCI, especially for patients with stable coronary artery disease.

Left Ventricular Function Recovery After Coronary Revascularization and Medical Therapy: A Systematic Review and Meta-Analysis

Background: The prevalence of coronary artery disease (CAD) with reduced left ventricular ejection fraction (LVEF) is rising, but the optimal treatment remains unclear. The present study aims to investigate the impact of revascularization (coronary artery bypass grafting (CABG), or percutaneous coronary intervention (PCI)) and medical therapy (MT) on LVEF recovery in patients with CAD and LVEF ≤ 40%. Methods: All clinical studies which reported LVEF in patients with CAD and LVEF ≤ 40% undergoing either revascularization or MT were included. A systematic literature search up to May 11, 2017 was performed on MEDLINE, EMBASE and the Cochrane Library in Ovid. Studies were assessed for eligibility and data were extracted by independent reviewers in duplicate with disagreements resolved by a third reviewer. Bias assessment was performed using the Newcastle-Ottawa Scale. Random effect meta-analysis was performed on included studies. The primary outcome was change in LVEF after intervention as compared to baseline. Results: 83 cohort studies with a total of 7,157 patients were included. We observed a statistically significant increase in LVEF following revascularization with CABG (MD 7.76; 95% CI: 6.81 to 8.70; p<0.00001; I 2 =99%) and PCI (MD 6.70; 95% CI: 4.71 to 8.70; p<0.00001; I 2 =94%) but not after MT (MD 4.06; 95% CI: -2.12 to 10.24; p=0.20; I 2 =98%). Conclusion: In patients with CAD and LVEF ≤ 40%, revascularization leads to LVEF recovery as compared to MT. There is continued need for RCT level evidence to enable optimization of treatment selection in this difficult population.

Stress-echocardiography or coronary computed tomography in suspected chronic coronary syndrome after the 2019 European Guidelines? A practical guide.

Stress-echocardiography can rightly be considered one of the champions of cardiac functional imaging, thanks to its real-time imaging, high temporal resolution, high safety and very low cost. When stress-echocardiography is performed at top technical quality, hence taking advantage of ultrasound contrast media for endocardial border delineation at least for suboptimal cases, subjectivity is minimized, and with the routine use of coronary flow reserve measurement (left anterior descending coronary artery, stress/rest ratio reduced or normal, i.e. <>2.0) diagnostic sensitivity is strengthened. The true competitor of any type of functional imaging, stress-echocardiography included, is nowadays coronary computed tomography angiography, which is instead a diagnostic method directly, noninvasively assessing coronary anatomy, apparently the holy grail for any cardiologist. The new 2019 Guidelines on chronic coronary syndrome of the European Society of Cardiology change the existing landscape and clinical practice, while they probably cannot clarify which type of test, functional or anatomic, should be first chosen in different clinical scenarios of suspected chronic coronary syndrome. We review the existing data and the authors' personal view in order to assess how functional stress-echocardiography compares with coronary computed tomography angiography regarding three main aspects: diagnosis of coronary artery disease, guidance of therapy (coronary revascularization versus medical therapy) and risk stratification.

The Impact of the ISCHEMIA Trial on Clinical Practice: an Interventionist's Perspective.

The International Study of Comparative Health Effectiveness with Medical and Invasive Approaches (ISCHEMIA) trial is the latest in a series of studies evaluating the role of coronary revascularization plus optimal medical therapy (invasive management) as compared to optimal medical therapy alone (conservative management) in the management of patients with stable ischemic heart disease. The "headline" results suggested invasive management did not reduce overall major adverse cardiac events in the intermediate term (~ 3.2years), although it did sustainably reduce angina. In addition, invasive management reduced spontaneous myocardial infarction, with potentially important beneficial consequences on both long-term mortality and quality of life. This review puts the ISCHEMIA trial into historical context, explores the trial's results and limitations and shows why revascularization remains an important adjunct to optimal medical therapy that should be considered by all patients with stable ischemic heart disease and the physicians who care for them.

MO543ASSESSMENT OF RISK FACTORS FOR CARDIOVASCULAR EVENTS AND MORTALITY IN DIALYSIS PATIENTS IN THE AURORA STUDY, A RETROSPECTIVE ANALYSIS

Abstract Background and Aims Patients with chronic kidney disease (CKD) are at higher risk of cardiovascular disease (CVD), which can also lead to end-stage renal disease (ESRD).1 As anaemia is an independent risk factor for CVD,2 treating anaemia might reduce CV events in this patient population. This study aimed to evaluate the impact of anaemia and other risk factors on long-term CV risk in haemodialysis (HD) patients with CKD. A secondary aim was to establish a CV risk equation for this patient population. Method This retrospective study used data from the Phase 3 AURORA study (NCT04042350) of 2776 ESRD patients aged 50–80 years receiving regular HD/haemofiltration, for a mean 3.2 year follow up.3 The primary endpoint of our analysis was time to first major adverse cardiovascular event (CV MACE; non-fatal stroke, non-fatal myocardial infarction, and CV mortality; n=804). Secondary endpoints included time to non-fatal stroke (ischaemic or haemorrhagic; n=98), coronary revascularisation therapy (n=300) and all-cause mortality (n=1296), and development of a CV risk equation. Ferritin and transferrin baseline values were determined for this analysis using the original frozen AURORA study patient samples (&amp;gt;10 years old). Statistical analyses were performed using univariate and multiple Cox regression models. For each outcome a full model was estimated and then simplified by approximation with fewer factors. This was done using linear regression against the linear predictor of the full Cox regression model. In a stepwise manner, the least contributing variable was removed until the subset of variables approximated the full model to 95%. Model performance was measured using the C-statistic, and internally validated using bootstrap. Results Incidence rates for CV MACE, non-fatal stroke, coronary revascularisation, and all-cause mortality were 9.36, 1.11, 3.57, and 13.73 per 100 patient-years, respectively. Certain established risk factors among HD patients, such as age, gender, previous history of CVD, diabetes mellitus, smoking, blood pressure, high phosphate and C-reactive protein levels, and low albumin levels, were also findings for this study, although non-fatal stroke was underpowered to show significance (Table). Elevated haemoglobin levels (≥127 g/L) demonstrated a protective effect on the risk of all-cause mortality (hazard ratio [HR] 0.916, p=0.010 for 127 g/L [upper quartile] versus 107 g/L [lower quartile]), but were also associated with an increased risk of coronary revascularisations (HR 1.164, p=0.011 for 127 g/L versus 107 g/L). Haemoglobin levels ≤107 g/L were associated with an approximately 9% increased annual risk of mortality (HR 1/0.916=1.092). Elevated ferritin and transferrin levels were significant and independent risk factors for CV MACE (HR [95% CI] 1.130 [1.025, 1.246] and 1.202 [0.987, 1.464], respectively), and all-cause mortality (HR [95% CI] 1.088 [1.008, 1.174] and 1.402 [1.198,1.641], respectively), but further analyses of iron metabolism markers, such as hepcidin, are needed to draw meaningful conclusions. The age of the samples may have also impacted the results. Risk prediction models were developed, and the predictive ability was 0.66–0.68 (C-statistic). Conclusion This analysis confirmed that this cohort is representative of a HD population. Moreover, elevated haemoglobin levels were associated with increased survival, concomitantly with coronary revascularisation. Elevated ferritin and transferrin levels were identified as potential risk factors for CV MACE and all-cause mortality, but further studies are required to better understand their value in estimating CV risk. Risk predication models were developed and performed well but require validation against an independent patient cohort.

Cardiac mortality in patients randomised to elective coronary revascularisation plus medical therapy or medical therapy alone: a systematic review and meta-analysis.

AimsThe value of elective coronary revascularisation plus medical therapy over medical therapy alone in managing stable patients with coronary artery disease is debated. We reviewed all trials comparing the two strategies in this population.Methods and resultsFrom inception through November 2020, MEDLINE, EMBASE, Google Scholar, and other databases were searched for randomised trials comparing revascularisation against medical therapy alone in clinically stable coronary artery disease patients. Treatment effects were measured by rate ratios (RRs) with 95% confidence intervals, using random-effects models. Cardiac mortality was the pre-specified primary endpoint. Spontaneous myocardial infarction (MI) and its association with cardiac mortality were secondary endpoints. Further endpoints included all-cause mortality, any MI, and stroke. Longest follow-up data were abstracted. The study is registered with PROSPERO (CRD42021225598). Twenty-five trials involving 19 806 patients (10 023 randomised to revascularisation plus medical therapy and 9783 to medical therapy alone) were included. Compared with medical therapy alone, revascularisation yielded a lower risk of cardiac death [RR 0.79 (0.67–0.93), P < 0.01] and spontaneous MI [RR 0.74 (0.64–0.86), P < 0.01]. By meta-regression, the cardiac death risk reduction after revascularisation, compared with medical therapy alone, was linearly associated with follow-up duration [RR per 4-year follow-up: 0.81 (0.69–0.96), P = 0.008], spontaneous MI absolute difference (P = 0.01) and percentage of multivessel disease at baseline (P = 0.004). Trial sequential and sensitivity analyses confirmed the reliability of the cardiac mortality findings. All-cause mortality [0.94 (0.87–1.01), P = 0.11], any MI (P = 0.14), and stroke risk (P = 0.30) did not differ significantly between strategies.ConclusionIn stable coronary artery disease patients, randomisation to elective coronary revascularisation plus medical therapy led to reduced cardiac mortality compared with medical therapy alone. The cardiac survival benefit after revascularisation improved with longer follow-up times and was associated with fewer spontaneous MIs.