Higher Revascularization Rate Research Articles

The prognosis evaluation of guideline-directed medical therapy for type 2 acute myocardial infarction patients with acute respiratory failure

Abstract Backgrounds Type 2 myocardial infarction (T2MI) arises from an imbalance between myocardial oxygen supply and demand during acute illness such as tachyarrhythmia, hypoxia, or hypotension without acute atherothrombosis. The efficacy of guideline-directed medical therapy (GDMT) in T2MI complicated by acute respiratory failure remains uncertain. Purposes This study was aimed to assess the impact of GDMT (including dual antiplatelet therapy, statins and β-blockers) on the prognosis of patients with T2MI and acute respiratory failure. Methods The data for this study were derived from a retrospective cohort of patients admitted to and discharged from 72 secondary and tertiary hospitals between 2010 and 2023. Inclusion criteria included patients with a discharge diagnosis of T2MI and acute respiratory failure. GDMT was defined according to the ACC/AHA Class I recommendations. Patients were divided into GDMT and N-GDMT groups, with differences in clinical characteristics adjusted using propensity score matching (PSM). Primary outcome indicators were major adverse cardiac and cerebrovascular events (MACCE), while secondary outcome indicators included in-hospital mortality, cardiac mortality, non-lethal myocardial infarction, recurrent ischemic stroke, bleeding events and revascularization. Results This study comprised 898 patients in the GDMT group and 3,777 in the N-GDMT group, resulting in 888 matched pairs after PSM. Baseline data showed that patients in the GDMT group had a higher burden of pre-existing comorbidities. In terms of treatment, the GDMT group had a higher proportion of patients undergoing Percutaneous Coronary Intervention (PCI) (4.84% vs. 1.80%, p= 0.001). In-hospital mortality was significantly lower in the GDMT group (12.4% vs. 26.4%, p< 0.001).Over amedian follow-up of 1,304 days, the incidence of MACCE within 1 month was significantly lower in the GDMT group (23.1% vs. 41.3%, p< 0.001). Furthermore, the GDMT group exhibited lower all-cause mortality (52.4% vs. 60.1%, p＜0.01) and cardiac mortality (41.3% vs. 50.3%, p< 0.001) compared to the N-GDMT group, with higher rates of revascularization (3.15% vs. 1.24%, p＜0.01). There were no statistically significant differences in the incidence of bleeding BARC3 (0.45% vs. 0.45%, p=1), recurrent non-lethal myocardial infarction (0.23% vs. 0%, p =0.5) and recurrent stroke (1.46% vs. 0.79%, p =0.261). GDMT at discharge was associated with a lower risk of MACCE in unadjusted analysis (HR=0.51, 95%CI= 0.44-0.59, p＜0.01) and after adjusting for age, gender, Killip classification and comorbidities in multivariate Coxregression analysis (aHR = 0.49, 95%CI= 0.41-0.58). Conclusions Adherence to GDMT was associated with a lower incidence of MACCE during 1-month follow-up, suggesting the importance of GDMT in this patient population.Clinical characteristics of patients

SOFIA Aspiration System as first-line Technique (SOFAST): a prospective, multicenter study to assess the efficacy and safety of the 6 French SOFIA Flow Plus aspiration catheter for endovascular stroke thrombectomy

BackgroundMechanical thrombectomy (MT) is the standard of care for acute ischemic stroke (AIS) patients with large vessel occlusion (LVO). The SOFAST study collected clinical evidence on the safety and efficacy...

Clinical outcomes of single- versus two-stent PCI technique in severely calcified true bifurcation lesions after rotational atherectomy.

Severely calcified coronary bifurcations complicate percutaneous coronary interventions (PCI) and often necessitate dedicated lesion preparation. We compared the outcomes of single- versus two-stent techniques for treating heavily calcified true bifurcation lesions following rotational atherectomy (RA). Among patients receiving RA for severely calcified true bifurcations at a single center, 59 were treated with a single stent, and another 59 received two stents. We analyzed in-hospital adverse outcomes and 1-year rates of the bifurcation-oriented composite endpoint (BOCE), defined as cardiac death, target bifurcation myocardial infarction (TB-MI), or target bifurcation revascularization (TBR). The single-stent arm was associated with more in-hospital adverse outcomes (adj. OR, 6.13; 95% CI, 1.34-28.0; p = 0.019), driven by higher peri-procedural MI rates (18.6% vs. 5.1%, p = 0.043) and more side branch compromise (13.6% vs. 0%, p = 0.006). After 1year, both techniques had comparable 1-year BOCE (adj. HR, 0.38; 95% CI, 0.12-1.23; p = 0.106). We observed a significant interaction between the treatment technique and the presence of LM bifurcation (p interaction = 0.012), favoring single-stent technique in patients with non-LM bifurcations (HR 0.14, 95% CI 0.03-0.68; p = 0.015). Notably, the single-stent technique had lower rates of TBR (2% vs. 15%, p log-rank = 0.026) after 1year. Patients with severely calcified true bifurcation lesions, treated with RA followed by a single stent implantation, had more in-hospital adverse outcomes compared to those treated with two stents. However, the superior outcomes of the two-stent technique did not translate into improved long-term results. In fact, the two-stent technique was even associated with higher rates of revascularization after 1year.

Revisión sistemática y metanálisis de estudios aleatorizados y no aleatorizados sobre revascularización guiada por reserva fraccional de flujo

Introduction and objectivesSeveral studies have investigated the effectiveness of fractional flow reserve (FFR) guidance in improving clinical outcomes after myocardial revascularization, yielding conflicting results. The aim of this study was to compare clinical outcomes in patients with coronary artery disease following FFR-guided or angiography-guided revascularization. MethodsBoth randomized controlled trials (RCTs) and nonrandomized intervention studies were included. Coprimary endpoints were all-cause death, myocardial infarction, and major adverse cardiovascular events (MACE). The study is registered with PROSPERO (CRD42022344765). ResultsA total of 30 studies enrolling 393 588 patients were included. FFR-guided revascularization was associated with significantly lower rates of all-cause death (OR, 0.63; 95%CI, 0.53-0.73), myocardial infarction (OR, 0.70; 95%CI, 0.59-0.84), and MACE (OR, 0.77; 95%CI, 0.70-0.85). When only RCTs were considered, no significant difference between the 2 strategies was observed for any endpoints. However, the use of FFR was associated with reduced rates of revascularizations and treated lesions. Metaregression suggested that the higher the rate of revascularized patients the lower the benefit of FFR guidance on MACE reduction compared with angiography guidance (P=.012). Similarly, higher rates of patients with acute coronary syndromes were associated with a lower benefit of FFR-guided revascularization (P=.039). ConclusionsFFR-guided revascularization was associated with lower rates of all-cause death, myocardial infarction and MACE compared with angiographic guidance, with RCTs and nonrandomized intervention studies yielding conflicting data. The benefits of FFR-guidance seem to be less evident in studies with high revascularization rates and with a high prevalence of patients with acute coronary syndrome.

Systematic review and meta-analysis of randomized and nonrandomized studies on fractional flow reserve-guided revascularization

Introduction and objectivesSeveral studies have investigated the effectiveness of fractional flow reserve (FFR) guidance in improving clinical outcomes after myocardial revascularization, yielding conflicting results. The aim of this study was to compare clinical outcomes in patients with coronary artery disease following FFR-guided or angiography-guided revascularization. MethodsBoth randomized controlled trials (RCTs) and nonrandomized intervention studies were included. Coprimary endpoints were all-cause death, myocardial infarction, and major adverse cardiovascular events (MACE). The study is registered with PROSPERO (CRD42022344765). ResultsA total of 30 studies enrolling 393 588 patients were included. FFR-guided revascularization was associated with significantly lower rates of all-cause death (OR, 0.63; 95%CI, 0.53-0.73), myocardial infarction (OR, 0.70; 95%CI, 0.59-0.84), and MACE (OR, 0.77; 95%CI, 0.70-0.85). When only RCTs were considered, no significant difference between the 2 strategies was observed for any endpoints. However, the use of FFR was associated with reduced rates of revascularizations and treated lesions. Metaregression suggested that the higher the rate of revascularized patients the lower the benefit of FFR guidance on MACE reduction compared with angiography guidance (P=.012). Similarly, higher rates of patients with acute coronary syndromes were associated with a lower benefit of FFR-guided revascularization (P=.039). ConclusionsFFR-guided revascularization was associated with lower rates of all-cause death, myocardial infarction and MACE compared with angiographic guidance, with RCTs and nonrandomized intervention studies yielding conflicting data. The benefits of FFR-guidance seem to be less evident in studies with high revascularization rates and with a high prevalence of patients with acute coronary syndrome.

Abstract 18145: Meta-Analysis Comparing Immediate and Staged Complete Revascularization for Multivessel Disease in Acute Coronary Syndrome Patients

Background: Acute coronary syndrome (ACS) patients undergoing PCI often have severe non-culprit vessel involvement known as multivessel disease (MVD), which is linked to worse outcomes. While guidelines recommend complete revascularization, the optimal timing is unclear. Comparing immediate vs. staged approaches is crucial to identify the optimal approach to revascularization. Research question: Do outcomes differ between immediate complete revascularization (ICRV) and staged complete revascularization (SCRV) in patients with ACS and MVD? Methods: PubMed, Cochrane library and Web of Science were searched for studies comparing immediate vs. staged complete revascularization for ACS and MVD. Randomized controlled trials (RCTs) and prospective studies reporting all-cause mortality, major adverse cardiac events (MACE), myocardial infarction (MI), and revascularization were included. Thirty-day and extended-term outcomes were evaluated, and risk ratios (RR) with 95% confidence intervals (CIs) were calculated using a random-effects model. Results: The meta-analysis comprised 6 RCTs and 5 prospective studies, involving 3,631 patients (ICRV: 1,728; SCRV: 1,903) presenting with ACS (ST-elevation MI (STEMI)=9, NSTEMI=1; Mixed=2). The mean age was 62.4 ± 9.4 years, with 79.5% male. The ICRV group exhibited significantly higher 30-day mortality (RR: 2.19 [1.31-4.06], p=0.004), while the SCRV group had higher revascularization rates at 30 days and extended term (RR: 0.27 [0.10-0.69], p=0.007 and RR: 0.68 [0.48-0.96], p=0.03, respectively). No significant difference was found in 30-day and extended-term MACE and MI between the ICRV and SCRV groups. Conclusion: Although there was no significant difference in overall MACE between the two complete revascularization strategies for patients with ACS and MVD, the SCRV group showed lower 30-day all-cause mortality, while the ICRV group demonstrated a lower incidence of revascularization rates.

Long-term outcome after implementation of endovascular-first strategy to treat acute mesenteric ischemia

ObjectiveTo evaluate the rationale of an aggressive endovascular-first strategy to treat elderly patients with acute mesenteric ischemia (AMI) by studying long-term survival, readmissions, and patients’ discharge to home vs nursing facility a decade after an episode of AMI. MethodsThe retrospective study cohort included 66 consecutive patients (all-comers) treated for arterial occlusive AMI between 2009 and 2013. Endovascular revascularization (EVR) was attempted in 50 patients (EVR+), whereas 16 patients were treated without attempted revascularization (EVR−). All patients were followed until death or September 2022. Studied outcomes included discharge status, long-term survival and cause of death and readmissions related to AMI. ResultsThe mean age of all 66 patients was 78 ± 10 years: 79 ± 9 years in the EVR+ group and 76 ± 12 years in the EVR− group. EVR was technically successful in 44 patients (88%); three patients underwent subsequent open revascularization after EVR failure. One-third required bowel resection after EVR. The 30-day mortality for all patients was 44%; 32% in the EVR+ group and 81% in the EVR− group. Only two survivors were permanently institutionalized, whereas all others were discharged to the same place they lived prior to the AMI episode. There were four AMI-related readmissions during the follow-up; all were in the EVR+ group. Two patients underwent reinterventions for recurrent AMI. One-year survival was 52% for EVR+ and 19% for EVR− patients. Five-year survival rates were 18% and 13%, respectively. The causes of deaths were mesenteric ischemia in 22, other cardiovascular event in 21, and non-cardiovascular cause in 19 patients. Four patients were alive at the end of the follow-up. ConclusionsIn this unselected elderly population with AMI, the aggressive strategy to attempt EVR resulted in a high revascularization rate and favorable outcomes. The high proportion of patients returning to their prior living status and low readmission rate after survival from AMI encourages active treatment of high-functioning elderly patients.

Stent reconstruction in intracranial atherosclerotic disease related acute ischemic stroke results in high revascularization rates

ObjectivesIntracranial atherosclerotic disease (ICAD) is a major cause of large vessel occlusion (LVO) in acute ischemic stroke (AIS). Our study aimed to analyze the effect of percutaneous transluminal angioplasty and stenting (PTAS) in patients with ICAD undergoing rescue treatment in terms of functional outcome and mortality rate at 90 days and compare the results to LVO with thromboembolic origins. Materials and methodsA retrospective review of a mechanical thrombectomy (MT) single center database from 01/2019 to 09/2021 was carried out using chart review and angiogram analysis. From 469 acute stroke patients, 361 patients were enroled in the study, of whom twenty-four (6.6%) were diagnosed with underlying ICAD and treated with angioplasty and stent reconstruction (PTAS) with a standardized medication protocol. Successful reperfusion, peri-procedural complications, and functional independence at 90 days were collected as outcomes. ResultsThere was no difference in age or admission National Institutes of Health Stroke Scale (NIHSS). Onset to groin puncture (median 460 vs 277 min, P = 0.019) was significantly longer in the ICAD group. The procedure time (median 73 vs 60 min, P = 0.137) did not differ. Successful reperfusion was achieved in 95.8% of ICAD and 91.1% of the remaining patients (P = 0.445). Functional independence (mRS ≤ 2) at 90 days was achieved in 45.8% (11/24) and 42.7% (144/337, (P = 0.767)). The mortality rates (mRS 6) at 90 days were similar (29.2% vs 29.4% (P = 0.983)). ConclusionDespite significantly longer treatment delays, the outcome and revascularization rates of ICAD patients were similar to the thromboembolic cohort. Our proposed protocol of PTAS and medication protocol in ICAD was effective with a similar safety profile as MT in general.

Feasibility and safety of ADAPT in acute distal posterior cerebral artery occlusions

PurposeThe direct aspiration first pass technique (ADAPT) is an effective and safe endovascular treatment for distal medium vessel occlusions (DMVO) of the anterior circulation. Clinical experience with ADAPT in the distal posterior circulation, however, is still limited and published data is scarce. In this original work, feasibility, safety and efficacy of ADAPT with distal access catheters (DAC) for treatment of acute distal posterior cerebral artery occlusions (DPCAOs) is evaluated. MethodAll acute ischemic stroke patients between 2017 and 2022 with primary or secondary DPCAOs in the P2 or P3 segment, that underwent thrombectomy of the DPACO using ADAPT with DACs as frontline therapy, were identified. Demographic data, recanalization rates, procedural safety, and clinical outcome were assessed. ResultsTwenty-four patients with primary (n = 6) or secondary (n = 18) DPCAOs (P2: 21/24; P3: 3/24) were included. Median NIHSS score at admission was 14.5 (IQR 9.5). In all cases, the DPCAO could be reached with the DAC. Successful revascularization (DMVO-p-TICI ≥ 2b) with ADAPT was achieved in 79.2% (19/24), including a first pass effect of 62.5% (15/24), leading to complete recanalization (DMVO-p-TICI 3). Median number of passes was 1 (range 1–2). No complications related to distal PCA aspiration thrombectomy occurred. Median NIHSS and mRS scores at discharge were 4 (IQR 8) and 3 (IQR 2), respectively. ConclusionsADAPT appears to be feasible, safe and effective for the treatment of acute DPCAOs in the setting of different occlusion patterns. High revascularization rates without procedural complications can be achieved. Further studies are needed to consolidate these results.

Unfavorable Cerebral Venous Outflow is associated with Futile Recanalization in Acute Ischemic Stroke Patients.

Mechanical thrombectomy (MT) has proven to be the standard of care for patients with acute ischemic stroke due to large vessel occlusion (AIS-LVO). However, high revascularization rates do not necessarily result in favorable functional outcomes. We aimed to investigate imaging biomarkers associated with futile recanalization, defined as unfavorable functional outcome despite successful recanalization in AIS-LVO patients. Retrospective multicenter cohort study of AIS-LVO patients treated by MT. Successful recanalization was defined as modified Thrombolysis in Cerebral Infarction (mTICI) score of 2b-3. A modified Rankin Scale (mRS) score of 3-6 at 90-days was defined as unfavorable functional outcome. Cortical Vein Opacification Score (COVES) was used to assess venous outflow (VO) and the Tan scale was utilized to determine pial arterial collaterals on admission computed tomography angiography (CTA). Unfavorable VO was defined as COVES ≤2. Multivariable regression analysis was performed to investigate vascular imaging factors associated with futile recanalization. Among 539 patients in which successful recanalization was achieved, unfavorable functional outcome was observed in 59% of patients. 58% of patients had unfavorable VO and 31% exhibited poor pial arterial collaterals. In multivariable regression, unfavorable VO was a strong predictor (adjusted odds ratio [95% CI]; 4.79 [2.48-9.23]) of unfavorable functional outcome despite successful recanalization. We observe that unfavorable VO on admission CTA is a strong predictor of unfavorable functional outcomes despite successful vessel recanalization in AIS-LVO patients. Assessment of VO profiles could help as a pretreatment imaging biomarker to determine patients at risk for futile recanalization.

Impact of Gender, Race, and Insurance Status on Inhospital Management and Outcomes in Patients With COVID-19 and ST-Elevation Myocardial Infarction (a Nationwide Analysis)

There is a paucity of data exploring the impact of gender, race, and insurance status on invasive management and inhospital mortality in patients with COVID-19 with ST-elevation myocardial infarction (STEMI) in the United States. The National Inpatient Sample database for the year 2020 was queried to identify all adult hospitalizations with STEMI and concurrent COVID-19. A total of 5,990 patients with COVID-19 with STEMI were identified. Women had 31% lower odds of invasive management and 32% lower odds of coronary revascularization than men. Black patients had lower odds of invasive management (odds ratio [OR] 0.61, 95% confidence interval [CI] 0.43 to 0.85, p=0.004) than White patients. Black and Asian patients had lower odds of percutaneous coronary intervention (Black: OR 0.55, 95% CI 0.38 to 0.80, p=0.002; Asian: OR 0.39, 95% CI 0.18 to 0.85, p=0.018) than White patients. Uninsured patients had higher odds of getting percutaneous coronary intervention (OR 1.78, 95% CI 1.05 to 2.98, p=0.031) and lower odds of inhospital mortality (OR 0.41, 95% CI 0.19 to 0.89, p=0.023) than privately insured patients. Patients with out-of-hospital STEMI had 19 times higher odds of invasive management and 80% lower odds of inhospital mortality than inhospital STEMI. In conclusion, we note important gender and racial disparities in invasive management of patients with COVID-19 with STEMI. Surprisingly, uninsured patients had higher revascularization rates and lower mortality than privately insured patients.

Nationwide trends of gatekeeper to invasive coronary angiography in suspected coronary artery disease

Abstract Funding Acknowledgements Type of funding sources: None. Background and Objectives Real-world trends in the utility and type of gatekeeping studies in invasive coronary angiography (ICA) requires further investigation. Methods We identified outpatients who underwent noninvasive cardiac tests or directly ICA for suspected coronary artery disease (CAD) from the nationwide Korea Health Insurance Review and Assessment Service-National Patient Sample database between 2012 and 2018. Results Among 71,401 patients, the percentage of patients who were evaluated for suspected CAD was 34.7% for treadmill test (TMT), 4.2% for single-photon emission computed tomography (SPECT), 24.2% for coronary computed tomography angiography (CCTA), 1.6% for multiple gatekeepers, and 32.3% for directly ICA without noninvasive studies (Figure 1). The proportion of CCTA as a gatekeeper showed linear increase, (18.6% in 2012 and 28.8% in 2018; p < 0.001), while those of TMT, SPECT, and direct ICA have decreased (p < 0.001, p = 0.03, and p < 0.001, respectively). The overall incidence of downstream ICA after gatekeeper was 13.8% (6,662/48,346), and SPECT showed higher ICA rate in pairwise comparison with TMT and CCTA (p < 0.001). Patients who performed gatekeepers before ICA showed higher rate of subsequent PCI (34.7% vs. 32.3%; p < 0.001) and CABG (3.5% vs. 1.0%; p < 0.001), compared to those who directly underwent ICA, and CCTA was associated with higher revascularization rate after ICA in pairwise comparison with TMT and SPECT (p < 0.001). Conclusion Nationwide database demonstrated that CCTA is utilized increasingly as a gatekeeper for ICA and is associated with high revascularization rate after ICA in outpatients with suspected CAD.

Implantable cardioverter-defibrillators for primary and secondary prevention of sudden cardiac death in clinical practice: analysis of the clinical and anamnestic characteristics of patients according to the Kuzbass registry

Aim. To study clinical and anamnestic data of patients with implantable cardioverterdefibrillators (ICD) for primary or secondary prevention of sudden cardiac death (SCD) based on the data from the Kuzbass ICD registry.Methods. Retrospective analysis of demographic, clinical and anamnestic data from the “Kuzbass Registry of Patients with Implanted Cardioverter-Defibrillator”, which includes 286 patients admitted at the Kuzbass Cardiology Center in 2015–2019, was carried out.Results. The age of patients included in the registry was 59 (53; 66) years, 239 (83.6%) were men; all patients were diagnosed with heart failure. ICD for primary prevention of SCD was prescribed in 171 (63.6%) patients (group 1) and for secondary prevention in 98 (36.4%) patients (group 2). The groups were comparable in age, sex, main nosology (coronary artery disease), left ventricular ejection fraction (31.4 (26; 35) and 30 (10; 68)%, p = 0.389). Compared with the group 2, the group 1 had fewer working patients, higher incidence of heart defects, severe heart failure, higher incidence of paroxysmal supraventricular tachycardia (68.7% versus 44.8%, p = 0.001), and higher rates of revascularization (48, 9% and 31.7%, respectively, p = 0.006). Before ICD implantation for heart failure, 210 (73.4%) patients were receiving renin angiotensin aldosterone system inhibitors, 259 (90.6%) – beta-blockers, 167 (58.4%) – mineralocorticoid receptor antagonists. There were no differences in prescribed treatment between the groups. Only 137 (47.9%) patients, 86 (47.3%) patients in the group 1 and 51 (49.0%) patients in the group 2 received triple neurohormonal blockade. Remote monitoring was used only within the framework of research programs.Conclusion. The primary cohort of patients with ICD is the primary SCD prevention group. Regardless of the type of SCD prevention, the underlying disease is coronary artery disease. Current guidelines for optimal drug therapy and myocardial revascularization are not always followed prior to ICD implantation. The creation of registries of patients with ICD is an effective way to identify existing problems in ICD patient selection and to optimize follow-up and treatment.

ENDOVASCULAR INTERVENTION FOR ACUTE ISCHEMIC STROKE AT CAN THO UNIVERSITY OF MEDICINE AND PHARMACY HOSPITAL

Introduction: Acute cerebral ischemic stroke is a life-threatening emergency with high incidence of mortality and morbidity. Endovascular revascularization has been increasingly used as one of the treatment options. In this article, we report our outcomes of endovascular intervention for the treatment of ischemic stroke and highlight some technical experiences. Materials and methods: A cross-sectional descriptive study was conducted on all cerebral ischemic stroke patients who came to Can Tho University of Medicine and Pharmacy Hospital within 8 hours from the first symptom would be included. National Institute of health stroke (NIHSS) scale was used for stroke grading which should be 10 or above. The vascularization procedure would be performed with the thrombus aspiration systems or stent retrievers with or without angioplasty and stenting. Postprocedure care would be conducted for at least 2 weeks before discharge. Results: A total of 53 patients were recruited from 1st of January 2018 to 30th December 2020 (24 months). Male to female ratio was 1.54:1. Ages ranged from 38 to 90 (mean 64). NIHSS scores ranged from 12-25. Approximately 98% of patients had comorbidities with hypertension, diabetes, atrial fibrillation , mitral valve stenosis and valvular insufficiency, A-V block. Totally there were 44 patients experiencing thrombectomy with catheter-based distal aspiration (35), stent retrievers (03), aspiration and stent retriever combination (06). The total technical success rates for all procedures were 47/53 (88.6%)). The total death rate was 15/53 (28.3%) due to combining comorbiditiese. There were 31/53 patients (58.4%) who had significant recovered in muscle movement, language and cognition after 2 weeks. Conclusion: Endovascular intervention is a one of the good options for the management of acute ischemic stroke, which has a high revascularization rate (88.6%) and can save up to 58.4% of patients out of disability. Successful revascularization is the crucial first step to salvage the patients and obtain a better prognosis.

Clinical and angiographic characteristics and short-term outcomes of patients with non-ST elevation acute coronary syndrome with metabolic syndrome

Abstract Funding Acknowledgements Type of funding sources: None. Background Less evidence is available regarding clinical, angiographic characteristics and outcomes of patients with non-ST elevation acute coronary syndrome (ACS) with metabolic syndrome (MS). Purpose We aimed to assess the clinical, angiographic characteristics and short-term outcomes of patients admitted to our hospital with non-ST elevation ACS with MS. Methods 128 patients with non-ST elevation ACS were enrolled in the study (Aged 38-75 years; mean age 56.2±16.85 years; male 53%). Patients were divided into two groups according to concomitant metabolic syndrome. Group I consisted of 64 patients with MS and Group II (n=64) without MS. Anthropometric, laboratory and instrumental data were assessed at baseline together with clinical and angiographic characteristics. All statistical analysis were done with STATA software. Results Non-ST elevation ACS patients with MS (Group I) tended to be younger (52.5 vs. 58.6, P<0.05), female gender (57% vs. 46%, P<0.05), smoked less (21.0 vs. 28.2%, P<0.05), having greater BMI (30.4 vs 26.8, P<0.05), having less pronounced symptoms (P<0.05) and greater extensive lesions in coronary angiography (P<0.05) than those without MS. There were similar single-vessel (52% vs. 55%, P>0.05) and multi-vessel (28% vs 26%, P>0.05) lesions in both groups in coronary angiography. New revascularization was higher in Group I than Group II (72% vs. 65%, P<0.05). In 12% of patients non-ST elevation ACS was occurred due to vasospasm in Group I and in 11% in Group II. There were similar hospitalization days in both groups (P>0.05), however short-term outcomes was better in Group II in 6 months (P<0.05). Conclusion MS is associated with higher rate of revascularization and worse outcome in patients presenting non-ST elevation ACS.

Refinement of Coronary Artery Bypass Grafting at Juntendo University Hospital.

Surgical treatment of ischemic heart disease began in 1945. After 1970, coronary artery bypass grafting (CABG) with cardiopulmonary bypass was developed along with coronary angiography. Juntendo University has been treating ischemic heart disease since 1980, and is actively performing off-pump CABG (OPCAB) since 2002. Besides the age of patients undergoing surgery, complications such as chronic hemodialysis, cerebrovascular disease, and malignancies make it challenging to reduce postoperative complications using OPCAB as graft preservation. OPCAB is technically challenging, and the CORONARY trial did not reveal its superiority over conventional CABG. Furthermore, high revascularization rates and technical differences among surgeons are important concerns. While not widely accepted in Europe and the United States, OPCAB comprises 65% of all stand-alone CABG in Japan. Japan reported a 2.5% hospital mortality rate in 2018, while the US reported 2.2% (according to the American Association of Thoracic Surgeons). In contrast, Juntendo University Hospital has maintained a 1% hospital mortality rate since 1984. To reduce the incidence of remote stroke in CABG patients, Juntendo has been using stroke-free management since 2010. Postoperative atrial fibrillation is 4-5 times more likely to recur than normal sinus rhythm after a 5-year course. In our study, 20% of patients suffered from chronic atrial fibrillation after ten years. Furthermore, left atrial appendage closure or amputation significantly reduces stroke in patients who undergo CABG and develop postoperative atrial fibrillation. Thus, OPCAB is a minimally invasive procedure with fewer complications; prevention of cardiogenic cerebral infarction can help improve remote outcomes.

Nationwide Trends of Gatekeeper to Invasive Coronary Angiography in Suspected Coronary Artery Disease

Real-world trends in the utility and type of gatekeeping studies in invasive coronary angiography (ICA) requires further investigation. We identified outpatients who underwent noninvasive cardiac tests or directly ICA for suspected coronary artery disease (CAD) from the nationwide Korea Health Insurance Review and Assessment Service-National Patient Sample database between 2012 and 2018. Among 71,401 patients, the percentage of patients who were evaluated for suspected CAD was 34.7% for treadmill test (TMT), 4.2% for single-photon emission computed tomography (SPECT), 24.2% for coronary computed tomography angiography (CCTA), 1.6% for multiple gatekeepers, and 32.3% for directly ICA without noninvasive studies. The proportion of CCTA as a gatekeeper showed linear increase, (18.6% in 2012 and 28.8% in 2018; p<0.001), while those of TMT, SPECT, and direct ICA have decreased (p<0.001, p=0.03, and p<0.001, respectively). The overall incidence of downstream ICA after gatekeeper was 13.8% (6,662/48,346), and SPECT showed higher ICA rate in pairwise comparison with TMT and CCTA (p<0.001). Patients who performed gatekeepers before ICA showed higher rate of subsequent PCI (34.7% vs. 32.3%; p<0.001) and CABG (3.5% vs. 1.0%; p<0.001), compared to those who directly underwent ICA, and CCTA was associated with higher revascularization rate after ICA in pairwise comparison with TMT and SPECT (p<0.001). Nationwide database demonstrated that CCTA is utilized increasingly as a gatekeeper for ICA and is associated with high revascularization rate after ICA in outpatients with suspected CAD.

Global Fractional Flow Reserve Value Predicts 5-Year Outcomes in Patients With Coronary Atherosclerosis But Without Ischemia.

BackgroundGlobal fractional flow reserve (FFR) (ie, the sum of the FFR values in the 3 major coronary arteries) is a physiologic correlate of global atherosclerotic burden. The objective of the present study was to investigate the value of global FFR in predicting long‐term clinical outcome of patients with stable coronary artery disease but no ischemia‐inducing stenosis.Methods and ResultsWe studied major adverse cardiovascular events (MACEs: all‐cause death, myocardial infarction, and any revascularization) after 5 years in 1122 patients without significant stenosis (all FFR >0.80; n=275) or with at least 1 significant stenosis successfully treated by percutaneous coronary intervention (ie, post–percutaneous coronary intervention FFR >0.80; n=847). The patients were stratified into low, mid, or high tertiles of global FFR (≤2.80, 2.80–2.88, and ≥2.88). Patients in the lowest tertile of global FFR showed the highest 5‐year MACE rate compared with those in the mid or high tertile of global FFR (27.5% versus 22.0% and 20.9%, respectively; log‐rank P=0.040). The higher 5‐year MACE rate was mainly driven by a higher rate of revascularization in the low global FFR group (16.4% versus 11.3% and 11.8%, respectively; log‐rank P=0.038). In a multivariable model, an increase in global FFR of 0.1 unit was associated with a significant reduction in the rates of MACE (hazard ratio [HR], 0.988; 95% CI, 0.977–0.998; P=0.023), myocardial infarction (HR, 0.982; 95% CI, 0.966–0.998; P=0.032), and revascularization (HR, 0.985; 95% CI, 0.972–0.999; P=0.040).ConclusionsEven in the absence of ischemia‐producing stenoses, patients with a low global FFR, physiologic correlate of global atherosclerotic burden, present a higher risk of MACE at 5‐year follow‐up.

PP329 An Australian Cost-Effectiveness Analysis Of The EluviaTM Drug-Eluting Stent For Treatment Of Symptomatic Lower-Limb Peripheral Artery Disease

IntroductionDespite advances in endovascular interventions, including the introduction of drug-eluting stents (DES), high target lesion revascularization (TLR) rates still burden the treatment of symptomatic lower-limb peripheral arterial disease (PAD). EluviaTM, a novel, sustained-release, paclitaxel-eluting DES, was shown to further reduce TLRs when compared with the paclitaxel-coated Zilver® PTX® stent, in the IMPERIAL randomized controlled trial. This evaluation estimated the cost-effectiveness of Eluvia when compared with Zilver PTX in Australia, based on 12-month clinical outcomes from the IMPERIAL trial.MethodsA state-transition, decision-analytic model with a 12-month time horizon was developed from an Australian public healthcare system perspective. Cost parameters were obtained from the Australian National Hospital Cost Data Collection Cost Report (2016–17). All costs were captured in Australian dollars (AUD), where AUD 1 = USD 0.69 (June 2020). Complete sets of clinical parameters (primary patency loss, TLR, amputation, and death) and cost parameters from their respective distributions were bootstrapped in samples of 1,000 patients, for each intervention arm of the model. One-way and probabilistic sensitivity analyses were performed.ResultsAt 12 months, modeled TLR rates were 4.5 percent for Eluvia and 8.9 percent for Zilver PTX, and mean total direct costs were AUD 6,537 [USD 4,511] and AUD 6,908 [USD 4,767], respectively (Eluvia average per patient savings; overall cohort=AUD 371 [USD 256]; diabetic cohort=AUD 625 [USD 431]). In probabilistic sensitivity analyses, Eluvia was cost-effective relative to Zilver PTX in 92.0 percent of all simulations at a threshold of $10,000 per TLR avoided. Eluvia was more effective and less costly (dominant) than Zilver PTX in 76.0 percent of simulations.ConclusionsIn the first year after the intervention, Eluvia was more effective and less costly than Zilver PTX, making Eluvia the dominant treatment strategy for treatment of symptomatic lower-limb PAD, from an Australian public healthcare system perspective. These findings should be considered when formulating policy and practice guidelines in the context of priority setting and making evidence-based resource allocation decisions for treatment of PAD in Australia.

Percutaneous coronary intervention with everolimus-eluting stents versus coronary artery bypass surgery in patients with stable angina and an isolated proximal left anterior descending artery disease

Abstract Background/Introduction Revascularization of the proximal segment of left anterior descending artery (pLAD) demonstrates an additional prognostic significance in survival for patients with multivessel disease. It is also indicated for symptomatic relief in patients with stable angina who are receiving optimal medical treatment in the presence of limiting angina or angina equivalent. Both coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI) are still commonly needed as therapeutic options for pLAD disease. Moreover, Everolimus-eluting stents (EES) have demonstrated superiority in safety and efficacy among other types of second or new generation drug-eluting stents. Purpose We aim to evaluate the long-term outcomes of PCI with EES compared to CABG surgery with left internal mammary artery, in patients with stable angina and an isolated single vessel pLAD disease. Methods The sample consisted of 824 patients with isolated pLAD and chronic stable angina; 445 participants were included in the EES-PCI group, and 379 were included in the CABG group. The study's primary endpoint was the occurrence of major adverse cardiac events (MACEs), namely, cardiac death, myocardial infarction (MI) not attributed to a non-target vessel and target lesion revascularization as a composite index. Secondary endpoints were Patient-Related Outcome (PRO; a composite index of all-cause mortality, any MI related to any coronary artery, any revascularization conducted to any coronary artery), individual components of MACEs, recurrence of stable or unstable angina or a nonfatal arrhythmia and disease progression of other lesions. For the comparisons between the two groups, chi-square tests and Fisher's exact tests, were used, as appropriate. Results During the 4.6 years of follow-up period, no statistically significant difference was observed between the two study groups in respect to the primary endpoint MACE (8.1% versus 7.4%, p=0.71). Concerning secondary endpoints, repeat revascularization (3.6% versus 2.9%, p=0.58), cardiac death (2.9% versus 3.2%, p=0.84), MI (1.6% versus 1.3%, p=0.76) and PRO (16.9% versus 17.7%, p=0.76) did not significantly differ between the two groups. Recurrence of angina was more frequent in the EES-PCI group (14.9% versus 8.4%, p=0.005) even though higher Class of angina was found less common in EES patients than in CABG patients (p&amp;lt;0.001). Patients treated with EES-PCI had lower rates of onset of arrhythmias compared to those treated with CABG (6.3% versus 11.9%, p=0.005). Finally, revascularization in other than target lesion was more frequent in the stent than in the surgery arm (6.3% versus 3.2%, p=0.04); as a consequence, higher rates of revascularization in any vessel was recorded in the PCI group than the CABG one (9.9% versus 5.8%, p=0.03). Conclusion PCI with EES seem to have similar long-term clinical outcomes compared with CABG in patients with isolated pLAD disease. Funding Acknowledgement Type of funding source: None