Elective Coronary Revascularization Research Articles

Anti-apolipoprotein A-1 IgG, incident cardiovascular events, and lipid paradox in rheumatoid arthritis

ObjectiveTo validate the prognostic accuracy of anti-apolipoprotein A-1 (AAA1) IgG for incident major adverse cardiovascular (CV) events (MACE) in rheumatoid arthritis (RA) and study their associations with the lipid paradox at a multicentric scale.MethodBaseline AAA1 IgG, lipid profile, atherogenic indexes, and cardiac biomarkers were measured on the serum of 1,472 patients with RA included in the prospective Swiss Clinical Quality Management registry with a median follow-up duration of 4.4 years. MACE was the primary endpoint defined as CV death, incident fatal or non-fatal stroke, or myocardial infarction (MI), while elective coronary revascularization (ECR) was the secondary endpoint. Discriminant accuracy and incidence rate ratios (IRR) were respectively assessed using C-statistics and Poisson regression models.ResultsDuring follow-up, 2.4% (35/1,472) of patients had a MACE, consisting of 6 CV deaths, 11 MIs, and 18 strokes; ECR occurred in 2.1% (31/1,472) of patients. C-statistics indicated that AAA1 had a significant discriminant accuracy for incident MACE [C-statistics: 0.60, 95% confidence interval (95% CI): 0.57–0.98, p = 0.03], mostly driven by CV deaths (C-statistics: 0.77; 95% CI: 0.57–0.98, p = 0.01). IRR indicated that each unit of AAA1 IgG increase was associated with a fivefold incident CV death rate, independent of models’ adjustments. At the predefined and validated cut-off, AAA1 displayed negative predictive values above 97% for MACE. AAA1 inversely correlated with total and HDL cholesterol.ConclusionsAAA1 independently predicts CV deaths, and marginally MACE in RA. Further investigations are requested to ascertain whether AAA1 could enhance CV risk stratification by identifying patients with RA at low CV risk.

Ischemia-Guided Coronary Revascularization Following Lower-Extremity Revascularization Improves 5-Year Survival of Patients With Chronic Limb-Threatening Ischemia.

To determine whether diagnosis of asymptomatic (silent) coronary ischemia using coronary computed tomography (CT)-derived fractional flow reserve (FFRCT) together with targeted coronary revascularization of ischemia-producing coronary lesions following lower-extremity revascularization can reduce adverse cardiac events and improve long-term survival of patients with chronic limb-threatening ischemia (CLTI). Prospective cohort study of CLTI patients with no cardiac history or symptoms undergoing elective lower-extremity revascularization. Patients with pre-operative coronary computed tomography angiography (CTA) and FFRCT evaluation with selective post-operative coronary revascularization (FFRCT group) were compared with patients with standard pre-operative evaluation and no post-operative coronary revascularization (control group). Lesion-specific coronary ischemia was defined as FFRCT≤0.80 distal to a coronary stenosis with FFRCT≤0.75 indicating severe ischemia. Endpoints included all-cause death, cardiac death, myocardial infarction (MI) and major adverse cardiovascular (CV) events (MACE=CV death, MI, stroke, or unplanned coronary revascularization) during 5 year follow-up. In the FFRCT group (n=111), FFRCT analysis revealed asymptomatic (silent) coronary ischemia (FFRCT≤0.80) in 69% of patients, with severe ischemia (FFRCT≤0.75) in 58%, left main ischemia in 8%, and multivessel ischemia in 40% of patients. The status of coronary ischemia in the control group (n=120) was unknown. Following lower-extremity revascularization, 42% of patients in FFRCT had elective coronary revascularization with no elective revascularization in controls. Both groups received guideline-directed medical therapy. During 5 year follow-up, compared with control, the FFRCT group had fewer all-cause deaths (24% vs 47%, hazard ratio [HR]=0.43 [95% confidence interval [CI]=0.27-0.69], p<0.001), fewer cardiac deaths (5% vs 26%, HR=0.18 [95% CI=0.07-0.45], p<0.001), fewer MIs (7% vs 28%, HR=0.21 [95% CI=0.10-0.47], p<0.001), and fewer MACE events (14% vs 39%, HR=0.28 [95% CI=0.15-0.51], p<0.001). Ischemia-guided coronary revascularization of CLTI patients with asymptomatic (silent) coronary ischemia following lower-extremity revascularization resulted in more than 2-fold reduction in all-cause death, cardiac death, MI, and MACE with improved 5 year survival compared with patients with standard cardiac evaluation and care (76% vs 53%, p<0.001). Silent coronary ischemia in patients with chronic limb-threatening ischemia (CLTI) is common even in the absence of cardiac history or symptoms. FFRCT is a convenient tool to diagnose silent coronary ischemia perioperatively. Our data suggest that post-surgery elective FFRCT-guided coronary revascularization reduces adverse cardiac events and improves long-term survival in this very-high risk patient group. Randomized study is warranted to finally test this concept.

Off-Pump Coronary Artery Bypass Grafting Does Not Confer Superior Outcomes Among Frail Patients

Off-pump coronary revascularization (OPCAB) has been proposed to benefit patients who are at a greater surgical risk because it avoids the use of extracorporeal circulation. Although, historically, older patients were considered high-risk candidates, recent studies implicate frailty as a more comprehensive measure of perioperative fitness. Yet, the outcomes of OPCAB in frail patients have not been elucidated. Thus, using a national cohort of frail patients, we assessed the impact of OPCAB relative to on-pump coronary revascularization (ONCAB). Patients who underwent first-time elective coronary revascularization were tabulated from the 2010 to 2020 Nationwide Readmissions Database. Frailty was assessed using the previously-validated Johns Hopkins Adjusted Clinical Groups indicator. Multivariable models were used to consider the independent associations between OPCAB and the key outcomes. Of ∼26,529 frail patients, 6,322 (23.8%) underwent OPCAB. After risk adjustment and compared with ONCAB, OPCAB was linked with similar odds of in-hospital mortality but greater likelihood of postoperative cardiac arrest (adjusted odds ratio [AOR] 1.53, confidence interval [CI] 1.13 to 2.07) and myocardial infarction (AOR 1.44, CI 1.23 to 1.69). OPCAB was further associated with greater odds of postoperative infection (AOR 1.22, CI 1.02 to 1.47) but decreased need for blood transfusion (AOR 0.68, CI 0.60 to 0.77). In addition, OPCAB faced a +0.86-day increase in length of stay (CI 0.21 to 1.51) but similar costs (β $1,610, CI -$1,240 to 4,460) relative to ONCAB. Although OPCAB was associated with no difference in mortality compared with ONCAB, it was linked with greater likelihood of postoperative cardiac arrest and myocardial infarction. Our findings demonstrate that ONCAB remains associated with superior outcomes, even in the growing population of frail patients who underwent coronary revascularization.

Early chest tube removal on the 1st postoperative day protocol of an enhanced recovery after cardiac surgery programme is safe.

The aim of this study was to assess the safety of early chest tube removal (CTR) protocol on the 1st postoperative day (POD1) of our Enhanced Recovery After Surgery (ERAS) programme by comparing the risk of postoperative pneumothorax, pleural and pericardial effusion requiring intervention and hospital mortality. All consecutive patients undergoing elective coronary revascularization and/or valve surgery between 2015 and 2021 were assessed in terms of their perioperative management pathways: conventional standard of care (control group) versus standardized systematic perioperative ERAS programme including an early CTR on POD1 (ERAS group). A propensity score matching was applied. The primary end-point was a composite of postoperative pneumothorax, pleural and pericardial effusion requiring intervention and hospital mortality. A total of 3153 patients were included. Propensity score analysis resulted in 2 groups well-matched pairs of 1026 patients. CTR on POD1 was significantly increased from 29.5% in the control group to 70.3% in the ERAS group (P < 0.001). The incidence of the primary end-point was 6.4% in the control group and 6.9% in the ERAS group (P = 0.658). Patients in the ERAS group, as compared with control group, had significant lower incidence of bronchopneumonia (9.0% vs 13.5%; P = 0.001) and higher incidence of mechanical ventilation ≤6 h (84.6% vs 65.2%; P < 0.001), length of intensive care unit ≤1 day (61.2% vs 50.8%; P < 0.001) and hospital ≤6 days (67.3% vs.43.2%; P < 0.001). CTR on POD1 protocol can be safely incorporated into a standardized systematic ERAS programme, enabling early mobilization, and contributing to the improvement of postoperative outcomes. Ethics committee of the French Society of Thoracic and Cardio-Vascular Surgery (CERC-SFCTCV-2022-09-13_23140).

Diagnosis and treatment of ischemia-producing coronary stenoses improves 5-year survival of patients undergoing major vascular surgery

ObjectivePatients undergoing vascular surgery procedures have poor long-term survival due to coexisting coronary artery disease (CAD), which is often asymptomatic, undiagnosed, and undertreated. We sought to determine whether preoperative diagnosis of asymptomatic (silent) coronary ischemia using coronary computed tomography (CT)-derived fractional flow reserve (FFRCT) together with postoperative ischemia-targeted coronary revascularization can reduce adverse cardiac events and improve long-term survival following major vascular surgery MethodsIn this observational cohort study of 522 patients with no known CAD undergoing elective carotid, peripheral, or aneurysm surgery we compared two groups of patients. Group I included 288 patients enrolled in a prospective Institutional Review Board-approved study of preoperative coronary CT angiography (CTA) and FFRCT testing to detect silent coronary ischemia with selective postoperative coronary revascularization in addition to best medical therapy (BMT) (FFRCT guided), and Group II included 234 matched controls with standard preoperative cardiac evaluation and postoperative BMT alone with no elective coronary revascularization (Usual Care). In the FFRCT group, lesion-specific coronary ischemia was defined as FFRCT ≤0.80 distal to a coronary stenosis, with severe ischemia defined as FFRCT ≤0.75. Results were available for patient management decisions. Endpoints included all-cause death, cardiovascular death, myocardial infarction (MI), and major adverse cardiovascular events (MACE [death, MI, or stroke]) during 5-year follow-up. ResultsThe two groups were similar in age, gender, and comorbidities. In FFRCT, 65% of patients had asymptomatic lesion-specific coronary ischemia, with severe ischemia in 52%, multivessel ischemia in 36% and left main ischemia in 8%. The status of coronary ischemia was unknown in Usual Care. Vascular surgery was performed as planned in both cohorts with no difference in 30-day mortality. In FFRCT, elective ischemia-targeted coronary revascularization was performed in 103 patients 1 to 3 months following surgery. Usual Care had no elective postoperative coronary revascularizations. At 5 years, compared with Usual Care, FFRCT guided had fewer all-cause deaths (16% vs 36%; hazard ratio [HR], 0.37; 95% confidence interval [CI], 0.22-0.60; P < .001), fewer cardiovascular deaths (4% vs 21%; HR, 0.11; 95% CI, 0.04-0.33; P < .001), fewer MIs (4% vs 24%; HR, 0.13; 95% CI, 0.05-0.33; P < .001), and fewer MACE (20% vs 47%; HR, 0.36; 95% CI, 0.23-0.56; P < .001). Five-year survival was 84% in FFRCT compared with 64% in Usual Care (P < .001). ConclusionsDiagnosis of silent coronary ischemia with ischemia-targeted coronary revascularization in addition to BMT following major vascular surgery was associated with fewer adverse cardiovascular events and improved 5-year survival compared with patients treated with BMT alone as per current guidelines.

Assessment of a goal-directed perfusion strategy through an oxygen delivery audit.

Evidence supports the role of oxygen delivery (DO2) in ameliorating acute kidney injury (AKI). While instrumentation for continuous DO2 measurement exists, a simplified method has been reported for targeting a specific DO2 index (DO2i), commonly referred to as a goal-directed perfusion (GDP) strategy, by using a reference table and available data such as body surface area and continuous haematocrit values. This simplified approach can also be used for quality auditing via archived data. This retrospective sequential audit was conducted to assess the impact of employing a GDP strategy within our institution by examining perfusion practices, DO2 levels and renal outcomes before and after implementation. A total of 246 patients undergoing elective primary coronary revascularisation were included: 125 patients in the pre-change group and 121 patients in the post-change group. A DO2i threshold above 280mL/min/m2 was targeted in the post-GDP group. While both groups maintained a mean DO2 above the threshold, the post-GDP group exhibited a higher average DO2i (311 vs 291mL/min/m2). The GDP strategy led to higher nadir DO2i (255 vs 225, p < .001) and was coupled with a reduction in the time below the 280mL/min/m2 threshold (30min vs 50min, p < .001). The average cardiac index in the post-GDP group was higher (1.87 vs 1.65, p < .001) while also demonstrating a smaller creatinine rise of 6.8% compared to 13.5% in the control group (p = .035). There was no difference in AKI or mortality rates between the groups. The implementation of the GDP strategy demonstrated an enhancement in oxygen delivery during cardiopulmonary bypass, primarily attributable to elevated pump flow rates. A statistically significant decrease in serum creatinine levels was observed. The published reference table emerged as a simple yet effective tool in optimising our GDP strategy.

Is There Long-Term Clinical Equipoise Between CABG and PCI for Isolated Left Anterior Descending Artery Disease?

Is There Long-Term Clinical Equipoise Between CABG and PCI for Isolated Left Anterior Descending Artery Disease?

#2700 RENAL OSTEODYSTROPHY AND CLINICAL OUTCOMES: RESULTS FROM THE BRAZILIAN REGISTRY OF BONE BIOPSY

Abstract Background and Aims Mineral and bone disorders caused by chronic kidney disease (CKD-MBD) encompass biochemical/hormonal abnormalities, soft tissue calcifications and bone morphological changes known as renal osteodystrophy (ROD). Data from prior studies have consistently shown that patients with CKD-MBD are susceptible to an increased risk of mortality, bone fractures and major cardiovascular outcomes. This study is a sub analysis of the Brazilian Registry of Bone Biopsy (REBRABO), a prospective, national multicenter cohort of patients with CKD who underwent bone biopsy, aimed at addressing the relationship between ROD type and the occurrence of bone fractures, hospitalizations, cardiovascular events, and a composite of all-cause mortality. Method During the period from August 2015 to December 2021, 511 patients with CKD who underwent bone biopsy and with diagnosis of ROD were included in REBRABO. Bone biopsy was indicated by medical reasons or research protocol. Were excluded from this analysis patients who lost their follow-up (N = 111), had no bone biopsy report (N = 40), had an estimated glomerular filtration rate &amp;gt; 90 mL/min (N = 28), not signed their consent (N = 24), had bone fragments inadequate for diagnosis (N = 23), had a bone biopsy indicated by a specialty other than nephrology (N = 6), or were &amp;lt; 18 years old (N = 4). Baseline was defined as the time when the patient underwent bone biopsy. The prospective analysis included data from patients who completed at least 12 months of follow-up. The mean follow- up was 1242 (693-1508) days. The following events were adjudicated: bone fractures, hospitalization, major cardiovascular events - MACEs (unstable angina, nonfatal acute myocardial infarction, elective or emergency coronary revascularization, transient ischemic attack, stroke, and cardiovascular death), and death. Bone fragments were obtained via transiliac bone biopsies using an electrical trephine after prelabeling with tetracycline (3 days) administered over two separate periods. The samples were classified as osteitis fibrosa (OF), mixed uremic osteodystrophy (MUO), adynamic bone disease (ABD), osteomalacia (OM) and normal/minor alterations, according to TMV system. Cox regression analysis was performed to detect independent determinants of clinical outcomes. Results A total of 275 patients were included. This was a population with a mean age of 52 (42– 60) years, 143 (52%) were men, 39 (14%) had diabetes, and 248 (90%) were on dialysis. During follow-up, a total of 28 bone fractures, 97 hospitalization events, 44 MACEs, and 70 deaths were reported, with incidence of 15.1% (4.4%/year), 49.5% (14.6%/year), 23.3% (6.85%/year) and 25.5% (7.5%/year), respectively. Patients who presented MACEs had lower serum hemoglobin levels [11.1 (9.6-12.6) vs. 12 (10.8-13.5; p = 0.026], higher prevalence of diabetes mellitus [11 (25%) vs. 15 (10%); p = 0.013] and previous cardiovascular disease [8 (18%) vs. 8 (5%); p = 0.008]. Age, previous cardiovascular disease, and proportion of serum phosphate levels out of the normal range were independent predictors for death [OR 1.046 (CI: 1.024-1.069), p = 0.0001; OR 1.856 (CI: 1.009-3.413), p = 0.04; OR: 1.942 (CI: 1.116-3.379), p = 0.019; respectively].Participants were grouped according to the ROD subtype as: OF (n = 113; 41%), ABD (n = 79; 29%), MUO (n = 59; 21%), OM (n = 12; 4%), and normal/minor alterations (n = 12; 4%). ROD subtypes were not related to incident outcomes. Conclusion The incidence of bone fractures, hospitalizations, cardiovascular events, and of a composite of all-cause mortality did not differ between the types of ROD.

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.

Inadequate response to antiplatelet therapy in patients with peripheral artery disease: a prospective cohort study

BackgroundPatients with peripheral artery disease (PAD) are treated with preventive strategies to improve the cardiovascular risk. The incidence of cardiovascular events and mortality however remains high in PAD populations. We therefore aimed to better characterize PAD patients suffering from cardiovascular events and mortality in order to tailor preventive treatment.MethodsBetween 2018 and 2020, 246 PAD outpatients (17 newly diagnosed, 229 with known PAD) were prospectively enrolled in this observational cohort study. Patient data and blood samples were collected after inclusion, and the primary composite endpoint (myocardial infarction, elective coronary revascularization, ischemic stroke, acute limb ischemia, mortality) was evaluated after one year. Secondary outcomes included platelet reactivity, measured using the VerifyNow assay, and medication adherence, assessed using the Morisky Medication Adherence Scale-8 (MMAS-8). Logistic regression models were used to identify associations between characteristics and the occurrence of events.ResultsThe cohort comprised 207 patients with claudication and 39 with chronic limb threatening ischemia. Twenty-six (10.6%) patients suffered from an event during follow-up. Prior myocardial infarction (OR 3.3 [1.4–7.7]), prior ischemic stroke (OR 4.5 [1.8–10.9]), higher levels of creatinine (OR 5.2 [2.2–12.6]), lower levels of high-density lipoprotein (OR 4.2 [1.5–10.6]) and lower haemoglobin levels (OR 3.1 [1.3–7.1]) were associated with events. Patients with events had more often high on-treatment platelet reactivity (HTPR) on aspirin (OR 5.9 [1.4–25.1]) or clopidogrel (OR 4.3 [1–19.3]). High adherence to medication was associated with the occurrence of events (OR 4.1 [1–18]).ConclusionsPatients suffering from cardiovascular events and mortality were characterized by prior cardiovascular events as compared to patients who did not experience any events. Antiplatelet therapy was not optimally protective despite high medication adherence, and HTPR was independently associated with the occurrence of events. More research is needed on alternative treatment strategies such as dual antiplatelet therapy or combinations with anticoagulant drugs.Trial registrationThe Medical Ethics Committee (METC) of the MUMC+ approved the study (NL63235.068.17) and the study was registered in the Netherlands Trial Register (NTR7250).

Lipid-Lowering Therapy Use and Intensification Among United States Veterans Following Myocardial Infarction or Coronary Revascularization Between 2015 and 2019.

Understanding how statins, ezetimibe, and PCSK9i (proprotein convertase subtilisin/kexin type 9 serine protease inhibitors) are prescribed after a myocardial infarction (MI) or elective coronary revascularization may improve lipid-lowering therapy (LLT) intensification and reduce recurrent atherosclerotic cardiovascular disease events. We described the use and intensification of LLT among US veterans who had a MI or elective coronary revascularization between July 24, 2015, and December 9, 2019, within 12 months of hospital discharge. LLT intensification was defined as increasing statin dose, or initiating a statin, ezetimibe, or a PCSK9i, overall and among those with an LDL-C (low-density lipoprotein cholesterol) ≥70 or 100 mg/dL. Poisson regression was used to determine patient characteristics associated with a greater likelihood of LLT intensification following hospitalization for MI or elective coronary revascularization. Among 81 372 index events (mean age, 69.0 years, 2.3% female, mean LDL-C 89.6 mg/dL, 33.8% with LDL-C <70 mg/dL), 39.7% were not taking any LLT, and 22.0%, 37.2%, and 0.6% were taking a low-moderate intensity statin, a high-intensity statin, and ezetimibe, respectively, before MI/coronary revascularization during the study period. Within 14 days, 3 months, and 12 months posthospitalization, 33.3%, 41.9%, and 47.3%, respectively, of veterans received LLT intensification. LLT intensification was most common among veterans taking no LLT (82.5%, n=26 637) before MI/coronary revascularization. Higher baseline LDL-C, having a lipid test, and attending a cardiology visit were each associated with a greater likelihood of LLT intensification, while age ≥75 versus <65 years was associated with a lower likelihood of LLT intensification within 12 months posthospitalization. Less than half of veterans received LLT intensification in the year after MI or coronary revascularization suggesting a missed opportunity to reduce atherosclerotic cardiovascular disease risk.

Coronary revascularization of patients with silent coronary ischemia may reduce the risk of myocardial infarction and cardiovascular death after carotid endarterectomy

BackgroundMajor adverse cardiac events (MACEs) are the primary cause of death after carotid endarterectomy (CEA). We sought to determine whether selective coronary revascularization of CEA patients with asymptomatic coronary ischemia can reduce the risk of MACEs, myocardial infarction (MI), and cardiac death after endarterectomy compared with CEA patients receiving standard cardiac evaluation and care. MethodsTwo groups of patients with no cardiac history or symptoms undergoing elective CEA were compared. Group I: patients enrolled in a prospective study of noninvasive preoperative cardiac evaluation using coronary computed tomography (CT)-derived fractional flow reserve (FFRCT) to detect asymptomatic (silent) coronary ischemia with selective postoperative coronary revascularization. Group II: matched Control patients with standard preoperative cardiac evaluation and no postoperative coronary revascularization. Lesion-specific coronary ischemia in group I was defined as FFRCT ≤ 0.80 distal to coronary stenosis with severe ischemia defined as FFRCT ≤ 0.75. End points included MACEs, cardiac death, MI, cardiovascular (CV) death, stroke, and all-cause death through 3-year follow-up. ResultsGroup I (n = 100) and group II (n = 100) patients were similar in age (68 vs 67 years), gender (65% vs 62% male), comorbidities, and indications for CEA (53% vs 48% symptomatic carotid stenosis). In group I, FFRCT analysis revealed lesion-specific coronary ischemia in 57% of patients, severe coronary ischemia in 44%, left main ischemia in 7%, and multivessel ischemia in 28%. The status of coronary ischemia in group II was unknown. CEA was performed without complications in both groups, and all patients received optimal postoperative medical therapy. In group I, elective coronary revascularization was performed in 33 patients (27 percutaneous coronary intervention; 6 coronary artery bypass grafting) 1 to 3 months after CEA. Group II patients had no elective coronary revascularization. During 3-year follow-up, compared with group II, group I patients had fewer MACEs (4% vs 17%, hazard ratio [HR]: 0.21 [95% confidence interval (CI): 0.07-0.63], P = .004), fewer cardiac deaths (2% vs 9%, HR: 0.20 [95% CI: 0.04-0.95], P = .030), fewer MIs (3% vs 17%, HR: 0.16 [95% CI: 0.05-0.54], P = .001), and fewer CV deaths (2% vs 12%, HR: 0.16 [95% CI: 0.004-0.07], P = .009). There were no significant differences in the rates of stroke or all-cause death. ConclusionsPreoperative diagnosis of silent coronary ischemia with selective coronary revascularization after CEA may reduce the risk of MACEs, cardiac death, MI, and CV death during 3-year follow-up compared with CEA patients receiving standard cardiac evaluation and care.

Impact of chronic coronary syndromes on cardiovascular hospitalization and mortality: the ESC-EORP CICD-LT registry

Abstract Background In Europe, global data on guideline adherence, potential geographic variations and determinants of major clinical events in chronic coronary syndromes (CCS) remain suboptimal. The European Society of Cardiology (ESC) EURObservational Research Programme (EORP) Chronic Ischemic Cardiovascular Disease Long-Term (CICD-LT) registry, a prospective European registry, was designed and conducted to describe the profile, care and outcomes of patients with CCS across the ESC countries Purpose We aimed to investigate clinical events at one-year follow-up from the ESC EORP CICD-LT Registry and identify the variables associated with an increased risk of clinical events. Methods Consecutive adults presenting with a diagnosis of CCS during a routine ambulatory visit or an elective coronary revascularisation procedure at participating centres were recruited across 154 centers from 20 countries between 1 May 2015 and 31 July 2018. Information on clinical and survival status was collected after 1 year from study inclusion. Composite events were cardio-vascular (CV) mortality and/or CV rehospitalisations, all-cause mortality and/or all cause rehospitalisation. A multivariable Cox regression analysis was performed to identify the independent predictors of each composite. Cox models were also performed with age, sex and region forced in the model. Significance levels of 0.05 were required to allow a variable to stay within the model. Co-linearity between all candidate variables (variables with p&amp;lt;0.05 in univariable) within the model and variables considered of relevant clinical interest were tested before proceeding to the multivariable model. Missing data were not imputed. Results One-year outcomes of 6655 patients from the 9174 recruited in this European registry were analyzed. Overall, 168 patients (2.5%) died, mostly from CV causes (n=97, 1.5%). Northern Europe had the lowest CV mortality rate, while southern Europe had the highest (0.5% vs 2.0%, p=0.04). Women had a higher rate of CV mortality compared with men (2.0% vs 1.3%, p=0.02). During follow-up, 1606 patients (27.1%) were hospitalised at least once, predominantly for CV indications (n=1220, 20.6%). Among the population with measured LDL-cholesterol level at one year, 1434 patients (66.5%) were above the currently recommended target. Age, history of atrial fibrillation, previous stroke, liver disease, chronic obstructive pulmonary disease or asthma, increased serum creatinine and impaired left ventricular function were each independently associated with an increased risk of CV death or hospitalization. Conclusion In the CICD registry, the majority of patients with CCS have uncontrolled CV risk factors. The mortality rate at one year was low, but these patients are frequently hospitalised for CV causes. Early identification of comorbidities may represent an opportunity for enhanced care and better outcomes. Funding Acknowledgement Type of funding sources: Other. Main funding source(s): The study was funded by the EORP program.

Undetectable High-Sensitivity Troponin T as a Gatekeeper for Coronary Computed Tomography Angiography in Patients Suspected of Acute Coronary Syndrome

Objectives: The aim of this study was to characterize the safety and efficiency of a strategy employing the limit of detection (LoD) of high-sensitivity troponin T (hs-TnT) as a gatekeeper for coronary computed tomography angiography (CCTA) in suspected acute coronary syndrome (ACS) patients in the emergency department (ED). Methods: We included suspected ACS patients who underwent CCTA and were evaluated with hs-TnT. Patients were categorized as below the LoD and at or above the LoD. The primary outcome was 30-day major adverse cardiac events (MACEs), defined as all-cause mortality, ACS, or coronary revascularization. Results: The study population consisted of 177 patients (mean age 55 ± 10 years, 50.3% women), and 16 (9.0%) patients reached the primary outcome. None of the patients died, while 13 had an adjudicated diagnosis of ACS, and 3 underwent elective coronary revascularization. There were 77 patients (44%) with an hs-TnT value below the LoD (MACEs; n = 1 [1.3%]) and 100 (56%) with at or above the LoD levels (MACEs; n = 15 [15%]). None of 67 patients with an hs-TnT value below the LoD and <50% stenosis on CCTA experienced MACEs. Out of the 10 patients with an hs-TnT value below the LoD and ≥50% stenosis on CCTA, 1 patient underwent elective percutaneous coronary revascularization. In patients with an hs-TnT value at or above the LoD, 74 patients had <50% stenosis on CCTA, and 2 patients (3%) were diagnosed with myocardial infarction without obstructive coronary artery disease confirmed on invasive angiography. Thirteen (50%) patients with an hs-TnT value at or above the LoD and ≥50% stenosis on CCTA experienced MACEs (11 ACS and 2 elective percutaneous coronary revascularizations). Conclusion: Our findings support that implementing the LoD of hs-TnT as a gatekeeper may reduce the need for CCTA in suspected ACS patients in the ED.

Management of Dyslipidemia in Women and Men with Coronary Heart Disease: Results from POLASPIRE Study

Cardiovascular diseases (CVDs) are the leading cause of death in Poland. Starting from 1992, a gradual decrease in mortality due to CVDs has been observed, which is less noticeable in women. Following this notion, we assessed sex differences in the implementation of ESC recommendations regarding lipid control and the use of statins as part of secondary CVDs prevention in 1236 patients with acute coronary syndrome or elective coronary revascularization within the last 6–24 months. During hospitalization women had more frequently abnormal TC levels than men (p = 0.035), with overall higher TC levels (p = 0.009) and lower HDL-C levels (p = 0.035). In the oldest group, they also had more frequently elevated LDL-C levels (p = 0.033). Similar relationships were found during the follow-up visit. In addition, women less often achieved the secondary lipid therapeutic goal for non-HDL-C (p = 0.009). At discharge from hospital women were less frequently prescribed statins (p = 0.001), which included high-intensity statins (p = 0.002). At the follow-up visit the use of high-intensity statins was still less frequent in women (p = 0.02). We conclude that women generally have less optimal lipid profiles than men and are less likely to receive high-intensity statins. There is a need for more organized care focused on the management of risk factors.

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.

Association of Gene Polymorphisms of Some Endothelial Factors with Stent Reendothelization after Elective Coronary Artery Revascularization.

Restenosis remains the main complication after percutaneous coronary interventions in patients with coronary heart disease. The causes of its development include, in particular, genetic factors. We studied polymorphic loci of genes encoding endothelin-1 (EDN1 rs5370), endothelin-1 receptor (EDNRA rs5333), endothelin-converting enzyme (ECE1 rs1076669), and endothelial NO synthase (eNOS rs1549758, eNOS rs1799983, and eNOS rs2070244) in the context of in-stent restenosis development. It was found that the analyzed polymorphisms of the endothelin system genes were more significant for patients aged ≥ 65 years, while the polymorphic loci of the endothelial NO synthase gene (eNOS rs1799983 and eNOS rs1549758) were predominantly associated with time of in-stent restenosis. The obtained results can be useful for comprehensive assessment of the restenosis risk factors and the choice of optimal treatment for patients with coronary heart disease before elective surgical intervention.

Diagnosis of silent coronary ischemia with selective coronary revascularization might improve 2-year survival of patients with critical limb-threatening ischemia

BackgroundPatients with critical limb-threatening ischemia (CLTI) have had poor long-term survival after lower extremity revascularization owing to coexistent coronary artery disease. A new cardiac diagnostic test, coronary computed tomography-derived fractional flow reserve (FFRCT), can identify patients with ischemia-producing coronary stenosis who might benefit from coronary revascularization. We sought to determine whether the diagnosis of silent coronary ischemia before limb salvage surgery with selective postoperative coronary revascularization can reduce the incidence of adverse cardiac events and improve the survival of patients with CLTI compared with standard care. MethodsPatients with CLTI and no cardiac history or symptoms who had undergone preoperative testing to detect silent coronary ischemia with selective postoperative coronary revascularization (group I) were compared with patients with standard preoperative cardiac clearance and no elective postoperative coronary revascularization (group II). Both groups received guideline-directed medical care. Lesion-specific coronary ischemia in group I was defined as FFRCT of ≤0.80 distal to a stenosis, with severe ischemia defined as FFRCT of ≤0.75. The endpoints included all-cause death, cardiovascular (CV) death, myocardial infarction (MI), major adverse CV events (i.MACE; CV death, MI, unplanned coronary revascularization, stroke) through 2 years of follow-up. ResultsGroups I (n = 111) and II (n = 120) were similar in age (66 ± 9 vs 66 ± 7 years), gender (78% vs 83% men), comorbidities, and surgery performed. In group I, unsuspected, silent coronary ischemia was found in 71 of 103 patients (69%), with severe ischemia in 58% and left main coronary ischemia in 8%. Elective postoperative coronary revascularization was performed in 47 of 71 patients with silent ischemia (66%). In group II, the status of silent coronary ischemia was unknown. The median follow-up was >2 years for both groups. The 2-year outcomes for groups I and II were as follows: all-cause death, 8.1% and 20.0% (hazard ratio [HR], 0.38; 95% confidence interval [CI], 0.18-0.84; P = .016); CV death, 4.5% and 13.3% (HR, 0.32; 95% CI, 0.11-0.88; P = .028); MI, 6.3% and 17.5% (HR, 0.33; 95% CI, 0.14-0.79; P = .012); and major adverse CV events, 10.8% and 23.3% (HR, 0.44; 95% CI, 0.22-0.88; P = .021), respectively. ConclusionsThe preoperative evaluation of patients with CLTI and no known coronary artery disease using coronary FFRCT revealed silent coronary ischemia in two of every three patients. Selective coronary revascularization of patients with silent coronary ischemia after recovery from limb salvage surgery resulted in fewer CV deaths and MIs and improved 2-year survival compared with patients with CLTI who had received standard cardiac evaluation and care. Prospective controlled studies are required to further define the role of FFRCT in the evaluation and treatment of patients with CLTI.

Myocardial stress perfusion scintigraphy for outcome prediction in patients with severe left ventricular systolic dysfunction.

We evaluated 1576 consecutive patients referred to MPS and stratified into 3 LV ejection fraction (LVEF) categories: ≤35%, 36-49%, and ≥ 50%. Patients with LVEF ≤35% were oldest, most often men, and with the highest likelihood of prior early (elective or urgent) coronary revascularization. They had also the highest values or summed stress score (SSS), summed rest score (SRS), and summed difference score (SDS), as well as the highest frequency of significant coronary artery disease, and a greater number of diseased vessels. In this subgroup, 32 cardiovascular death or non-fatal myocardial infarction (MI) (21%), 35 all-cause deaths (22%), and 37 cardiovascular deaths, non-fatal MI, or late revascularizations (27%) were recorded with the shortest survival among all LVEF classes. SRS, SSS, and SDS had very low area under the curve values for the prediction of the 3 endpoints, with very high cut-offs, respectively. SRS and SSS cut-offs predicted a worse outcome in Cox regression models including the number of diseased vessels and early revascularization. In patients with LVEF ≤35%, SRS and SSS are less predictive of outcome than in patients with better preserved systolic dysfunction, but their cut-offs retain independent prognostic significance from the number of vessels with significant stenoses and from early revascularization.

Diagnosis and Treatment of Silent Coronary Ischemia May Reduce Adverse Cardiac Events and Improve Long-Term Survival of Patients Undergoing Lower-Extremity Revascularization

Background: Patients with Peripheral Artery Disease (PAD) undergoing lower-extremity revascularization are at increased risk of death and Myocardial Infarction (MI) due to co-existing Coronary Artery Disease (CAD) which is often unrecognized due to absence of chest pain symptoms. A new cardiac diagnostic test, coronary CT-derived Fractional Flow Reserve (FFRCT), can identify patients with unsuspected (silent) coronary ischemia. We sought to determine whether pre-operative diagnosis of silent coronary ischemia using FFRCT can facilitate multidisciplinary care to reduce post-operative death and MI and improve survival of PAD patients. Methods: Symptomatic PAD patients with no cardiac history or symptoms were enrolled in a prospective, open-label study of coronary CTA and FFRCT testing before lower-extremity revascularization and were compared to historic control patients with standard pre-operative cardiac evaluation and care. Lesion-specific coronary ischemia was defined as FFRCT ≤ 0.80 distal to a coronary stenosis. Endpoints included Cardiovascular (CV) death, MI and allcause death through 1 year follow up. Results: Baseline characteristics of the CTA-FFRCT (n=135) and Control (n=135) groups were similar with regard to age (66 ± 8 years), gender, co-morbidities and indication for surgery (>80% for CLTI). CTA-FFRCT evaluation revealed unsuspected (silent) coronary ischemia in 68% of patients and 40% of patients had elective post-operative coronary revascularization (PCI in 47, CABG in 7). The status of coronary ischemia was unknown in Control patients and none had elective coronary revascularization. At one year, CTA-FFRCT had fewer CV deaths (0.7% vs. 5.9%, p=0.04) and MIs (2.2% vs. 8.1%, p=0.03) and improved survival (99.3% vs. 94.1%, p=0.02) compared to Control. Conclusion: Pre-operative diagnosis of silent coronary ischemia in patients undergoing lower-extremity revascularization surgery can identify high-risk patients and facilitate multi-disciplinary patient care with selective post-operative coronary revascularization. This strategy reduced post-operative death and MI and improved one-year survival compared to standard care.