Coronary Stenting In Patients Research Articles

The role of acetylsalicylic acid in the treatment of diseases caused by atherosclerosis

Arterial involvement in atherosclerosis is systemic in nature and is not limited to a single vessel causing ischemic symptoms. Atherosclerotic plaques at various stages of development are simultaneously present in arteries of a patient with atherosclerosis, and many of them undergo cycles of rupture and repair without any clinical manifestations. The chronic use of antithrombotic drugs is one of the ways to prevent the development of clinically significant thrombosis after atherosclerotic plaque destabilization. For this purpose antiplatelet agents, are used in patients with diseases caused by atherosclerosis, who do not have indications for long-term use of high (therapeutic) doses of anticoagulants. At present, acetylsalicylic acid maintains a leading position of the main antithrombotic drug in monotherapy and a must component of composite antithrombotic therapy. Recent studies have limited its role only in certain clinical settings: (1) a prolonged (more than 1 month) use after coronary stenting in patients requiring a long-term use of high (therapeutic) doses of oral anticoagulants; (2) a long-term use after coronary stenting in some patients receiving acetylsalicylic acid combined with ticagrelor; (3) use as first-line drug monotherapy in patients with symptomatic atherosclerosis of arteries of the lower extremities; (4) a long-term use as first-line drug monotherapy after ischemic non-cardioembolic stroke. The use of acetylsalicylic acid requires adequate patient adherence to treatment and sufficient bioavailability of the active substance. When there are doubts on proper bioavailability, it is reasonable to use nonenteric-coated dosage forms of acetylsalicylic acid.

Aspirin vs Clopidogrel for Long-term Maintenance After Coronary Stenting in Patients With Diabetes

Selecting the optimal antiplatelet agent in patients who have received percutaneous coronary intervention is especially important in those with diabetes due to the heightened risk of ischemic events in this population. Studies on the efficacy and safety of clopidogrel vs aspirin for long-term maintenance after percutaneous coronary intervention in patients with diabetes are lacking. To investigate cardiovascular outcomes with clopidogrel vs aspirin in patients with and without diabetes. This was a post hoc analysis of the HOST-EXAM randomized clinical trial, an investigator-initiated, prospective, randomized, open-label, multicenter trial performed at 37 centers in Korea. Patients who received dual antiplatelet therapy without clinical events for 6 to 18 months after percutaneous coronary intervention with drug-eluting stents were enrolled from March 2014 to May 2018 with follow-up at 6, 12, 18, and 24 months. All 5438 patients in the original trial were included in this analysis, which was conducted from June to October 2021. Enrolled patients were randomized 1:1 to clopidogrel or aspirin monotherapy. Subgroup analyses were performed by the presence of diabetes. The main outcome was primary composite end point of all-cause death, nonfatal myocardial infarction, stroke, readmission due to acute coronary syndrome, and major bleeding (Bleeding Academic Research Consortium type 3 or 5) at 24-month follow-up. Of 5438 patients (mean [SD] age, 63.5 [10.7] years; 1384 [25.5%] female), 1860 (34.2%) had diabetes (925 in the clopidogrel arm and 935 in the aspirin arm), and 5338 (98.2%) completed follow-up. The rate of the primary composite end point was significantly lower in the clopidogrel group compared to the aspirin group in patients with diabetes (6.3% vs 9.2%; hazard ratio [HR], 0.69; 95% CI, 0.49-0.96; P = .03; absolute risk difference [ARD], 2.7%; number needed to treat [NNT], 37) and without diabetes (5.3% vs 7.0%; HR, 0.76; 95% CI, 0.58-1.00; P = .046; ARD, 1.6%, NNT, 63; P for interaction = .65). The presence of diabetes was not associated with a difference in benefit observed with clopidogrel monotherapy over aspirin for the thrombotic composite end point (HR, 0.68; 95% CI, 0.45-1.04 for patients with diabetes vs HR, 0.68; 95% CI, 0.49-0.93 for those without; P for interaction = .99) and any bleeding with Bleeding Academic Research Consortium 2, 3, or 5 (HR, 0.65; 95% CI, 0.39-1.09 for patients with diabetes vs HR, 0.74; 95% CI, 0.48-1.13 for those without; P for interaction = .71). In this study, clopidogrel monotherapy was associated with a lower rate of the primary composite end point compared to aspirin monotherapy as long-term maintenance therapy after dual antiplatelet therapy for coronary stenting in both patients with and without diabetes. Clopidogrel might thus be considered rather than aspirin in patients who have undergone coronary stenting and successfully completed dual antiplatelet therapy, regardless of diabetes status. ClinicalTrials.gov Identifier: NCT02044250.

The impact of systemic changes on quality of care providing in acute myocardial infarction in Ukraine

For the past 5 years, the system of providing medical care to patients with acute myocardial infarction (AMI) has radically changed in Ukraine. The accession of our country to the European initiative "Stent for Life" contributed to the creation of the national reperfusion network. It ensured the wide availability of medical care for patients with AMI due to the fastest delivery of patients to clinics that provide a 24-hour emergency coronary artery stenting. Nowadays in Ukraine, 42 reperfusion centers are successfully operating 24/7/365 care delivery and more than 50% of patients with AMI undergo primary percutaneous coronary intervention (PCI). Almost 70% of patients are delivered to clinics within the first 6 hours after the onset of AMI symptoms, which corresponds to the obligatory “therapeutic window” for emergency PCI. The average number of primary PCI performed in AMI increased by 4 times in 2018 compared to 2012, reaching 286 procedures per 1 million population. The structure of reperfusion therapy has qualitatively changed in 2016. The total number of reperfusion procedures increased due to a decrease of thrombolytic therapy cases and an increase in the frequency of using the most effective method – primary coronary stenting in patients with STEMI. Systemic changes in the structure of medical care providing to patients with AMI contributed to a decrease in hospital lethality in patients with AMI - from 14,1% in 2012 to 13,81% in 2019.

Abbreviated Antiplatelet Therapy After Coronary Stenting in Patients With Myocardial Infarction at High Bleeding Risk

BackgroundThe optimal duration of antiplatelet therapy (APT) after coronary stenting in patients at high bleeding risk (HBR) presenting with an acute coronary syndrome remains unclear. ObjectivesThe objective of this study was to investigate the safety and efficacy of an abbreviated APT regimen after coronary stenting in an HBR population presenting with acute or recent myocardial infarction. MethodsIn the MASTER DAPT trial, 4,579 patients at HBR were randomized after 1 month of dual APT (DAPT) to abbreviated (DAPT stopped and 11 months single APT or 5 months in patients with oral anticoagulants) or nonabbreviated APT (DAPT for minimum 3 months) strategies. Randomization was stratified by acute or recent myocardial infarction at index procedure. Coprimary outcomes at 335 days after randomization were net adverse clinical outcomes events (NACE); major adverse cardiac and cerebral events (MACCE); and type 2, 3, or 5 Bleeding Academic Research Consortium bleeding. ResultsNACE and MACCE did not differ with abbreviated vs nonabbreviated APT regimens in patients with an acute or recent myocardial infarction (n = 1,780; HR: 0.83; 95% CI: 0.61-1.12 and HR: 0.86; 95% CI: 0.62-1.19, respectively) or without an acute or recent myocardial infarction (n = 2,799; HR: 1.03; 95% CI: 0.77-1.38 and HR: 1.13; 95% CI: 0.80-1.59; Pinteraction = 0.31 and 0.25, respectively). Bleeding Academic Research Consortium 2, 3, or 5 bleeding was significantly reduced in patients with or without an acute or recent myocardial infarction (HR: 0.65; 95% CI: 0.46-0.91 and HR: 0.71; 95% CI: 0.54-0.92; Pinteraction = 0.72) with abbreviated APT. ConclusionsA 1-month DAPT strategy in patients with HBR presenting with an acute or recent myocardial infarction results in similar NACE and MACCE rates and reduces bleedings compared with a nonabbreviated DAPT strategy. (Management of High Bleeding Risk Patients Post Bioresorbable Polymer Coated Stent Implantation With an Abbreviated Versus Prolonged DAPT Regimen [MASTER DAPT]; NCT03023020)

Ticagrelor monotherapy after coronary stenting in patients requiring proton pump inhibitor and prolonged antiplatelet therapy.

Key Points Approximately half of patients undergoing coronary stenting are discharged on a proton‐pump inhibitor (PPI). Post‐hoc analysis of the large GLOBAL LEADERs trial finds PPI treatment and aspirin monotherapy after a year of dual antiplatelet therapy (DAPT) is associated with increased risk of ischemic events. In contrast, PPI treatment and continued ticagrelor monotherapy are not associated with increased ischemic events in the second year after stenting. This observational evidence suggests the GLOBAL LEADERS tested ticagrelor monotherapy regimen could be considered in patients requiring both prolonged antiplatelet therapy (>12 months) and PPI for increased bleeding risk.

A Prospective, observational, Italian multi-center registry of self-aPposing® cOronary Stents in patients presenting with ST-segment Elevation Myocardial InfarcTION: The iPOSITION registry.

BackgroundPrimary percutaneous coronary intervention (pPCI) in ST-segment elevation myocardial infarction (STEMI) can be challenging for high thrombus burden and catecholamine-induced vasoconstriction. The Xposition-S stent was designed to prevent stent undersizing and minimize strut malapposition. We evaluated 1-year clinical outcomes of a nitinol, self-apposing®, sirolimus-eluting stent, pre-mounted on a novel balloon delivery system, in de novo lesions of patients presenting with STEMI undergoing pPCI.MethodsThe iPOSITION is a prospective, multicenter, post-market, observational study. The primary endpoint, target lesion failure (TLF), was defined as the composite of cardiac death, recurrent target vessel myocardial infarction (TV-MI), and clinically driven target lesion revascularization (TLR).ResultsThe study enrolled 247 STEMI patients from 7 Italian centers. Both device and procedural success occurred in 99.2% of patients, without any death, TV-MI, TLR, or stent thrombosis during the hospital stay and at 30-day follow-up. At 1 year, TLF occurred in 2.6%, cardiac death occurred in 1.7%, TV-MI occurred in 0.4%, and TLR in 0.4% of patients. The 1-year stent thrombosis rate was 0.4%.ConclusionsThe use of an X-position S self-apposing® stent is feasible in STEMI pPCI, with excellent post-procedural results and 1-year outcomes.

Experience of using intra-aortic balloon counterpulsation during coronary bypass surgery and coronary stenting in patients with reduced left ventricular ejection fraction and mitral regurgitation of ischemic genesis

AIM: To analyze the changes in the degree of mitral regurgitation (MR) of ischemic origin and of clinical outcomes in patients with reduced left ventricular ejection fraction (LVEF) and multi-vascular coronary artery disease during use of intra-aortic balloon counterpulsation (IABC).
 MATERIALS AND METHODS: The results of the treatment of 186 patients with ischemic mitral insufficiency who underwent intra-aortic balloon counterpulsation as a preoperative preparation in connection with a low LVEF were outlined in this manuscript. The patients were divided into 2 groups. Group 1 included 132 patients who underwent coronary bypass surgery while Group 2 included 54 patients who underwent coronary artery stenting. The dynamics of MR and LVEF before and after left ventricular revascularization were studied on the basis of echocardiographic data.
 RESULTS: In group 1, there was a decrease in the degree of mitral regurgitation by 58% using IABC (p 0.05) in the early postoperative period (based on the measurement of vena contracta, v.c., the width of the regurgitation jet on the valve), and by 54% (p 0.05) in more than 6 months following surgical treatment. In group 2, there was a significant decrease in the degree of MR (based on v.c.) by 42% (p 0.05) in the early postoperative period and by 41% (p 0.05) in more than 6 months following surgical treatment.
 CONCLUSION: The use of intra-aortic balloon counterpulsation in patients with low LVEF, moderate and severe MI, and with significant coronary artery pathology, led to the reduction in the duration of surgical treatment and the time of using artificial blood circulation through by excluding the need for the correction of MI, both directly during surgical revascularization and in the long-term period (more than 6 months).

Investigation of dual antiplatelet therapy after coronary stenting in patients with chronic kidney disease.

Dual antiplatelet therapy (DAPT) is currently the standard treatment for the prevention of ischemic events after stent implantation. However, the optimal DAPT duration remains elusive for patients with chronic kidney disease (CKD). Therefore, we aimed to compare the effectiveness and safety between long-term and short-term DAPT after coronary stenting in patients with CKD. This retrospective cohort study analyze data from the Taipei Medical University (TMU) Institutional and Clinical Database, which include anonymized electronic health data of 3 million patients that visited TMU Hospital, Wan Fang Hospital, and Shuang Ho Hospital. We enrolled patients with CKD after coronary stenting between 2008 and 2019. The patients were divided into the long-term (>6 months) and short-term DAPT group (≤ 6 months). The primary end point was major adverse cardiovascular events (MACE) from 6 months after the index date. The secondary outcomes were all-cause mortality and Thrombolysis in Myocardial Infarction (TIMI) bleeding. A total of 1899 patients were enrolled; of them, 1112 and 787 were assigned to the long-term and short-term DAPT groups, respectively. Long-term DAPT was associated with similar risk of MACE (HR: 1.05, 95% CI: 0.65-1.70, P = 0.83) compare with short-term DAPT. Different CKD risk did not modify the risk of MACE. There was also no significant difference in all-cause mortality (HR: 1.10, 95% CI: 0.75-1.61, P = 0.63) and TIMI bleeding (HR 1.19, 95% CI: 0.86-1.63, P = 0.30) between groups. Among patients with CKD and coronary stenting, we found that long-term and short-term DAPT tied on the risk of MACE, all-cause mortality and TIMI bleeding.

Sex-based outcomes in contemporary antiplatelet therapy trials

Balancing ischaemic and bleeding risks in high-risk populations undergoing percutaneous coronary interventions has become an everyday dilemma for clinicians. It is particularly difficult to make decisions concerning combinations and duration...

Inhibition of Platelet Aggregation After Coronary Stenting in Patients Receiving Oral Anticoagulation.

Approximately 18% of patients with atrial fibrillation undergo a percutaneous coronary intervention (PCI) to treat coronary heart disease. Pharmacological anticoagulation in patients with atrial fibrillation and PCI involves a trade-off of potential ischemic and hemorrhagic complications. This review is based on pertinent publications that were retrieved by a selective literature search, including current guidelines and recommendations. Dual antiplatelet therapy (DAPT) with acetylsalicylic acid (ASA) and a P2Y12 inhibitor protects against stent thrombosis, but not against thromboembolic stroke. In contrast, oral anticoagulation does provide effective prevention against stroke during atrial fibrillation. Combining DAPT with oral anticoagulation (triple therapy) over the long term, as has been recommended to date, carries an elevated risk of hemorrhage. In a randomized controlled trial, 44% of patients with atrial fibrillation receiving triple therapy sustained a hemorrhagic event, compared to 19.4% of patients receiving dual therapy. A meta-analysis has shown that clinically relevant hemorrhage is less common under combined treatment with one of the new oral anticoagulants (NOAC) and a single antiplatelet drug than under triple therapy including a vitamin K antagonist (hazard ratio, 0.56; 95% confidence interval 0.39; 0.80]), but no significant difference was found with respect to stent thrombosis, myocardial infarction, or overall mortality. After coronary stent implantation, dual therapy with a NOAC and a P2Y12 inhibitor is recommended, subsequent to triple therapy given only during the peri-interventional period.

Patient Perspectives on the Benefits and Risks of Percutaneous Coronary Interventions: A Qualitative Study.

BackgroundGrowing evidence for coronary stents in patients with stable coronary artery disease (CAD) suggests that the benefits of stents are uncertain. The goal of this study was to assess patients’ informational needs and how patients react to information about the uncertain benefit of stents to CAD patients.MethodsSemi-structured qualitative interviews (N=20) were conducted with patients with stable CAD who received a recent stent. Data were coded and analyzed using a mixed inductive-deductive approach.ResultsSome patients mistakenly believed that the purpose of their stent was to prevent a future heart attack, and few were previously aware of the uncertain benefit. Nearly all patients perceived positive outcomes from their procedure, even if their symptoms persisted. Some patients had difficulty accepting evidence that stents may not reduce the risk of heart attack or reliably improve symptoms. Nonetheless, patients still expressed a desire to receive new information about the uncertain benefits of stents and wanted to have received this information early in their care.ConclusionMany patients with stable CAD do not understand the intended benefit of coronary stents and want to be informed of the evidence of uncertain benefit of coronary stents, even if this would not change their decision. Improved communication and patient education tools are needed to better inform patients. An intervention providing patients with this information early has the potential to solve these problems.

Optimized strategy of rotational atherectomy of underexpanded coronary stents in patients with acute coronary syndrome.

Stent under-expansion is a main cause of acute coronary syndrome (ACS), which can lead to serious clinical outcomes. The rotational atherectomy of underexpanded coronary stents (academically called stent ablation, SA) by intravascular ultrasound (IVUS) may provide more visual reference in the intervention. We aim to analyze the procedural and long-term outcomes of the optimized strategy of SA in patients with ACS and to provide real-world data on this technique. A total of 11 patients with ACS who underwent SA between April 2017 and January 2019 were analyzed. Clinical follow-ups were obtained either by telephone call or by scheduled visit. Clinical end-points included periprocedural and postprocedural myocardial infarction, stent thrombosis, target lesion revascularization, and major adverse cardiac events. The mean age of patients was 69.6±6.5 years, and five (45.5%) patients were males. All cases presented with unstable angina and were admitted with ACS. All patients required at least two burrs during the intervention and the size of the burr was selected based on the data of minimum lumen diameter (MLD), and the first and the second burr/stent MLD ratios were 0.93 (0.88-0.99) and 1.09 (1.02-1.14), respectively. Nine patients were treated with drug-eluting stents and two were treated with drug-coated balloons. There were no complications including no flow, perforation, or burr entrapment during the intervention. No in-hospital deaths or major adverse cardiac events were documented during the follow-up period. In our study, less contrast agent and a lower dose of radiation were used during the intervention. SA guided by IVUS can reduce the risk of complications, assess the results of surgery, inform the selection of stent size, and decrease the required dose of radiation and contrast.

The Bioengineered Combo Dual-Therapy CD34 Antibody-Covered Sirolimus-Eluting Coronary Stent in Patients with Chronic Total Occlusion Evaluated by Clinical Outcome and Optical Coherence Tomography Imaging Analysis.

We sought to determine the effects of the use of a Bioengineered Combo Dual-Therapy CD34 Antibody-Covered Sirolimus-Eluting Coronary Stent (Combo® DTS) in patients with chronic total occlusion (CTO) by evaluating clinical outcomes and by performing an optical coherence tomography (OCT) analysis. We retrospectively analyzed data from 39 patients who had successfully undergone OCT-guided revascularization of a CTO being treated with a Combo® DTS. Clinical assessment, angiography (with quantitative coronary angiography analysis) and OCT examination were performed at baseline and at follow-up. The median follow-up period was 189 days, ranging from 157 to 615 days. At follow-up, revascularization was required due to angiographic restenosis in 40% (14 of 35) of patients. OCT analysis detected neointima proliferation in 23 (76.6%) patients. Neointima formation was often associated with microvessels in 18 patients (60%). Neoatheroslcerosis was observed in 2 (6.6%) patients. Malapposition was found in 4 patients (13.3%), and stent fractures were found in 11 patients (36.6%). Rate of strut coverage was 96.3% at follow-up. In conclusion, the implantation of a Combo® DTS after successful CTO recanalization was associated with a restenosis rate of 40% despite good stent implantation at baseline, proven by OCT. Neointima formation was found as a main contributor to restenosis. Nevertheless, we observed a low rate of major cardiovascular events in our follow-up.

IMPACT OF PRIOR PERCUTANEOUS CORONARY INTERVENTION ON THE SHORT-TERM OUTCOME OF CORONARY ARTERY BYPASS SURGERY

IntroductionThe emergence of drug-eluting stents (DES) has resulted in greater utilization of coronary stents in patients with Class I Indications for Coronary Artery Bypass Surgery. The need for repeat revascularization in patients treated with PCI has led to an increasing percentage of CABG in patients with prior PCI. A study from the Society of Thoracic Surgeons 2018 Adult Cardiac surgery Database revealed that 28.9% of patients referred for CABG had a prior PCI. Several studies have demonstrated worse mid-term and long-term outcomes after CABG in patients with prior PCI. This study aimed to assess the impact of prior successful PCI on the short-term outcome after CABG surgery.Aim of the workThis study aimed to assess the impact of prior successful PCI on the short-term outcome after CABG surgery. Subjects and MethodsThis was a prospective cohort study that included a total of 60 patients admitted at The New Alexandria University Hospital from January 2018 to January 2020. Of these, 30 patients (50%) CABG surgery on native coronary arteries (Group A), and the remaining 30 patients (50%) had prior PCI before CABG (Group B). The primary outcomes of interest were postoperative myocardial infarction, cardiac death, postoperative bleeding, exploration for bleeding. Secondary outcomes included the duration of the ICU stay, the ventilation time, and the inotropic use.

Short-duration triple antithrombotic therapy for atrial fibrillation patients who require coronary stenting: results of the SAFE-A study.

We aimed to determine whether shortening the duration of P2Y12 inhibitor therapy can reduce the risk of bleeding without increasing the risk of major adverse cardiovascular events following coronary stenting in patients with atrial fibrillation (AF). The SAFE-A is a randomised controlled trial that compared one-month and six-month P2Y12 inhibitor therapy, in combination with aspirin and apixaban for patients with AF who require coronary stenting. The primary endpoint was the incidence of any bleeding events, defined as Thrombolysis In Myocardial Infarction major/minor bleeding, bleeding with various Bleeding Academic Research Consortium grades, or bleeding requiring blood transfusion within 12 months after stenting. The study aimed to enrol 600 patients but enrolment was slow. Enrolment was terminated prematurely after enrolling 210 patients (72.7±8.2 years; 81% male). The incidence of the primary endpoint did not differ between the one-month and six-month groups (11.8% vs 16.0%; hazard ratio [HR] 0.70, 95% confidence interval [CI]: 0.33-1.47; p=0.35). The study evaluated the safety of withdrawing the P2Y12 inhibitor from triple antithrombotic prescription one month after coronary stenting. However, enrolment was prematurely terminated because it was slow. Therefore, statistical power was not sufficient to assess the differences in the primary endpoint.

Polymer-free drug-coated vs. bare-metal coronary stents in patients undergoing non-cardiac surgery: a subgroup analysis of the LEADERS FREE trial.

To compare the outcomes of patients undergoing non-cardiac surgery (NCS) after PCI with either a drug-coated stent (DCS) or a bare-metal stent (BMS), followed by 1-month dual antiplatelet therapy and to explore the impact of the timing of NCS. This is a subgroup analysis of the LEADERS FREE trial. The primary safety end point was a composite of cardiac death, myocardial infarction, or stent thrombosis, and the primary efficacy end point was clinically driven target lesion revascularization (TLR). Out of 2432 patients included in the LEADERS FREE trial, 278 (11.4%) underwent NCS within 1 year after PCI. Among NCS patients, the 1-year safety end point was numerically lower with DCS; however, this difference was not significant as compared to BMS (4.7% vs. 10.1%, HR: 0.459 [0.178-1.183], p = 0.099), clinically driven TLR was significantly lower after DCS (2.4% vs. 8.3%, HR: 0.281 [0.079-0.996], p = 0.036), and BARC 3-5 bleeding was similarwith DCS vs. BMS (10.2% vs. 7.5%, p = 0.438). In patients treated with BMS, NCS within 3 months after PCI was associated with higher incidence of the safety end point than NCSs performed later: 14.9% vs. 4.4%, HR: 3.586 [1.012-12.709], p = 0.034. The timing of surgery had no impact on patients treated with DCS (4.7% vs. 4.7%, p = 0.947). Among patients undergoing NCS after PCI, DCS-treated patients had a lower probability of clinically driven TLR compared with BMS. However, there was no significant difference in the occurrence of the primary composite safety end point or bleeding complications. Early NCS after BMS-PCI was associated with impaired safety, while the timing of NCS had no such influence after DCS implantation.

The effect of coronary stent type on the long-term results of coronary artery bypass surgery after stenting clinically related artery in acute coronary syndrome in patients with multivessel coronary artery disease

Justification. The results of endovascular revascularization are largely determined by the type of stents used. The use of baremetal coronary stents significantly worsens the long-term results of endovascular treatment of coronary artery disease. Given the widespread use of bare-metal coronary stents in the Russian Federation for the treatment of coronary artery disease and acute coronary syndrome, in particular, the issue of the impact of the above-mentioned endovascular interventions on the long-term results of coronary artery bypass grafting (CABG) performed after endovascular revascularization of the clinically related artery in patients with acute coronary syndrome and multivessel lesions does not lose relevance.Aim. To compare the long-term results of the staged strategies of revascularization of the coronary bed: CABG performed after stenting the clinically related artery with third-generation biodegradable polymer-based sirolimus-eluting stents for acute coronary syndrome and CABG performed after stenting the clinically related artery with bare-metal coronary stents for acute coronary syndrome.Material and Methods. The analysis used the data of two-year follow-up of patients who underwent two-stage revascularization: at the first stage, patients received stenting of the clinically related artery for acute coronary syndrome and, at the second stage, they received coronary artery bypass grafting no later than 90 days from the date of stenting. The study included 218 patients with multivessel lesions of the coronary bed, admitted with clinical manifestation of acute coronary syndrome. The long-term follow-up period was 24 months. The following end points were analyzed: cardiovascular mortality, myocardial infarction, re-revascularization, and combined MACCE end point (cardiovascular mortality, myocardial infarction, acute cerebrovascular accident, and re-revascularization). The observation was carried out at the hospital stage and, then, on an outpatient basis once every three months.Results. There were no significant differences between the groups. The frequency of repeated revascularization, including repeated revascularization of the stented artery, and recurrence of angina were significantly higher in the group with baremetal coronary stents. There were no significant differences between the groups in regard to cardiovascular mortality, nonfatal myocardial infarction and acute cerebrovascular accidents. The frequency of MACCE events was significantly higher in the group of bare-metal coronary stents, mainly due to the frequency of repeated revascularizations.Conclusion. Coronary artery bypass grafting performed in the early period after stenting of the clinically related artery using bare-metal coronary stents in patients with acute coronary syndrome and multivessel lesions was associated with a significantly larger number of repeated coronary revascularizations and higher rate of recurrent angina compared to a similar strategy, but with the use of modern third-generation biodegradable polymer-based sirolimus-eluting stents.

Edoxaban-based versus vitamin K antagonist-based antithrombotic regimen after successful coronary stenting in patients with atrial fibrillation (ENTRUST-AF PCI): a randomised, open-label, phase 3b trial

We aimed to assess the safety of edoxaban in combination with P2Y12 inhibition in patients with atrial fibrillation who had percutaneous coronary intervention (PCI). ENTRUST-AF PCI was a randomised, multicentre, open-label, non-inferiority phase 3b trial with masked outcome evaluation, done at 186 sites in 18 countries. Patients had atrial fibrillation requiring oral anticoagulation, were aged at least 18 years, and had a successful PCI for stable coronary artery disease or acute coronary syndrome. Participants were randomly assigned (1:1) from 4 h to 5 days after PCI using concealed, stratified, and blocked web-based central randomisation to either edoxaban (60 mg once daily) plus a P2Y12 inhibitor for 12 months or a vitamin K antagonist (VKA) in combination with a P2Y12 inhibitor and aspirin (100 mg once daily, for 1-12 months). The edoxaban dose was reduced to 30 mg per day if one or more factors (creatinine clearance 15-50 mL/min, bodyweight ≤60 kg, or concomitant use of specified potent P-glycoprotein inhibitors) were present. The primary endpoint was a composite of major or clinically relevant non-major (CRNM) bleeding within 12 months. The primary analysis was done in the intention-to-treat population and safety was assessed in all patients who received at least one dose of their assigned study drug. This trial is registered with ClinicalTrials.gov, NCT02866175, is closed to new participants, and follow-up is completed. From Feb 24, 2017, through May 7, 2018, 1506 patients were enrolled and randomly assigned to the edoxaban regimen (n=751) or VKA regimen (n=755). Median time from PCI to randomisation was 45·1 h (IQR 22·2-76·2). Major or CRNM bleeding events occurred in 128 (17%) of 751 patients (annualised event rate 20·7%) with the edoxaban regimen and 152 (20%) of 755 patients (annualised event rate 25·6%) patients with the VKA regimen; hazard ratio 0·83 (95% CI 0·65-1·05; p=0·0010 for non-inferiority, margin hazard ratio 1·20; p=0·1154 for superiority). In patients with atrial fibrillation who had PCI, the edoxaban-based regimen was non-inferior for bleeding compared with the VKA-based regimen, without significant differences in ischaemic events. Daiichi Sankyo.

Better Prognosis After Complete Revascularization Using Contemporary Coronary Stents in Patients With Chronic Kidney Disease.

The prognostic value of angiographic complete revascularization in patients with chronic kidney disease (CKD) has not been thoroughly investigated, especially for contemporary coronary stents. We compared the clinical outcomes of complete and incomplete revascularization with second-generation drug-eluting stent, according to the presence of CKD. From the Grand Drug-Eluting Stent Registry (N=17 286) in Korea, we selected 8471 patients, who were treated with second-generation drug-eluting stent and had glomerular filtration rate and quantitative coronary angiography data (3014 [35.6%] patients with CKD and 5457 (64.4%) patients with preserved renal function). Angiographic complete revascularization was defined as a residual SYNTAX score (Synergy Between Percutaneous Coronary Intervention With Taxus and Cardiac Surgery) of 0. The primary outcome was the patient-oriented composite outcome at 3 years, including all-cause death, any myocardial infarction, and any revascularization. The patient-oriented composite outcome rate after complete revascularization was significantly lower than that after incomplete revascularization in patients with CKD (14.6% versus 21.8%; adjusted hazard ratio, 0.79; 95% CI, 0.64-0.96; P=0.020) and in patients with preserved renal function (8.0% versus 12.0%; adjusted hazard ratio 0.77; 95% CI, 0.63-0.94; P=0.011). The cutoff values of residual SYNTAX scores for predicting better patient-oriented composite outcomes were different according to the presence of CKD, that is, <3 and <8 in patients with CKD and with preserved renal function, respectively. Angiographic complete revascularization led to better clinical outcomes in patients with CKD and with preserved renal function. However, the residual SYNTAX score to achieve a better outcome was lower in patients with CKD than with preserved renal function, favoring more aggressive revascularization in patients with CKD.

Impact of tissue protrusion after coronary stenting in patients with ST-segment elevation myocardial infarction

Clinical impact of tissue protrusion (TP) after coronary stenting is still controversial, especially in patients with ST-segment elevation myocardial infarction (STEMI). A total of 104 STEMI patients without previous MI who underwent primary percutaneous coronary intervention (PCI) under intravascular ultrasound (IVUS)-guidance were included. Post-stenting grayscale IVUS analysis was performed, and the patients were classified according to the presence or absence of post-stenting TP on IVUS. Coronary angiography and single-photon emission computed tomography myocardial perfusion imaging (SPECT MPI) with 99mTc tetrofosmin were analyzed. Major adverse cardiac events were defined as cardiovascular death, myocardial infarction, heart failure hospitalization, and target vessel revascularization. TP on IVUS was detected in 62 patients (60%). Post-PCI coronary flow was more impaired, and peak creatine kinase-myoglobin binding level was higher in patients with TP compared to those without. SPECT MPI was performed in 77 out of 104 patients (74%) at 35.4 ± 7.7 days after primary PCI. In patients with TP, left ventricular ejection fraction was significantly reduced (47.5 ± 12.0% vs. 57.6 ± 11.2%, p < 0.001), and infarct size was larger [17% (8-25) vs. 4% (0-14), p = 0.002] on SPECT MPI. During a median follow-up of 14 months after primary PCI, Kaplan-Meier analysis demonstrated a significantly higher incidence of major adverse cardiac events in patients with TP compared to those without. TP on IVUS after coronary stenting was associated with poor outcomes in patients with STEMI.