Lower Risk Of Cardiac Death Research Articles

Abstract 4137467: Intravascular ultrasound-guided versus angiography-guided percutaneous coronary intervention: A systematic review, meta-analysis, and meta-regression of randomized controlled trials

Background: Intravascular ultrasound (IVUS) guidance during percutaneous coronary intervention (PCI) allows better visualization of atherosclerotic plaques than angiography alone. We conducted a systematic review and meta-analysis to comprehensively synthesize the available evidence regarding the efficacy of IVUS-guidance compared to angiography-guided PCI. Moreover, we conducted a sensitivity analysis to determine the applicability of IVUS guidance in complex PCI. Methods: We conducted a comprehensive literature search of major bibliographic databases from inception until May 2024 to identify randomized controlled trials (RCTs) comparing IVUS-guided versus angiography-guided PCI. Risk ratios (RR) with their corresponding 95% confidence intervals (CI) were pooled using the random-effects model, with a p-value <0.05 considered statistically significant. We conducted meta-regression to determine the moderating of baseline covariates on pooled outcomes. Results: Sixteen RCTs were included with 10,993 patients undergoing PCI (IVUS-guided PCI: 5684 patients; angiography-guided PCI: 5157 patients). IVUS-guided PCI demonstrated a significantly lower risk of cardiac death [RR: 0.49; 95% CI: 0.35, 0.68], major adverse cardiovascular events [RR: 0.64; 95% CI: 0.51, 0.80], myocardial infarction [RR: 0.73; 95% CI: 0.59, 0.89], stent thrombosis [RR: 0.45; 95% CI: 0.27, 0.75], target lesion revascularization [RR: 0.60; 95% CI: 0.49, 0.74], and target vessel revascularization [RR: 0.56; 95% CI: 0.45, 0.70] than angiography-guided PCI. IVUS-guided PCI demonstrated a nonsignificant trend toward a reduced risk of all-cause mortality [RR: 0.79; 95% CI: 0.61, 1.04]. Meta-regression showed a nonsignificant moderating effect of the duration of follow-up, age of patients, baseline dyslipidemia, and hypertension status on pooled outcomes. A sensitivity analysis was conducted for patients undergoing complex PCI. The sensitivity analysis showed the superiority of IVUS-guided PCI compared to angiography-guided PCI by resulting in a significant improvement in the clinical outcomes. Conclusion: This meta-analysis concluded that IVUS-guided PCI resulted in a reduction in cardiac death, major adverse cardiovascular events, myocardial infarction, stent thrombosis, target lesion revascularization, and target vessel revascularization, compared to angiography-guided PCI. Moreover, we observed the superiority of IVUS guidance in complex PCI as well.

Intravascular imaging-guided PCI in patients with acute myocardial infarction and cardiogenic shock

Abstract Background There are no clinical data regarding efficacy of intravascular imaging-guided percutaneous coronary intervention (PCI) compared with angiography-guided PCI in patients with acute myocardial infarction (AMI) and cardiogenic shock. Purpose The current study sought to evaluate the impact of intravascular imaging-guided PCI in patients with AMI and cardiogenic shock. Methods Among a total of 28,732 patients from the nationwide pooled registry of KAMIR-NIH and KAMIR-Ⅴ, a total of 1,833 patients (6.4%) with AMI and cardiogenic shock who underwent PCI of the culprit vessel were selected. The primary endpoint was major adverse cardiovascular events (MACE) at 1 year, a composite of cardiac death, MI, repeat revascularization, and definite or probable stent thrombosis. Results Among the study population, 375 patients (20.5%) underwent intravascular imaging-guided PCI and 1,458 patients (79.5%) underwent angiography-guided PCI. Intravascular imaging-guided PCI showed significantly lower risk of 1-year MACE compared with angiography-guided PCI (19.5% vs 28.2%; adjusted hazard ratio [HR], 0.59; 95% confidence interval [CI], 0.45-0.77; P<0.001), mainly driven by lower risk of cardiac death (13.7% vs. 24.0%; adjusted HR, 0.53; 95% CI, 0.39-0.72; P<0.001). These results were consistent in propensity score matching (HR, 0.68; 95% CI, 0.46-0.99), inverse probability weighting (HR, 0.61; 95% CI, 0.45-0.83), and Bayesian analysis (odds ratio, 0.66, 95% credible interval, 0.49-0.88). Conclusion In AMI patients with cardiogenic shock, intravascular imaging-guided PCI was associated with lower risk of MACE at 1-year than angiography-guided PCI, mainly driven by the lower risk of cardiac death. Further randomized controlled trial is warranted to confirm these findings.Central illustration

Dose-Response Independent and Joint Associations of Physical Activity and Sedentary Behavior With Mortality Risk in 40 156 Australian Adults With Coronary Heart Disease.

Little is known about the relationship between physical activity (PA) and sedentary behavior (SB) with death in people with coronary heart disease. The aim was to examine the independent and joint associations of PA and SB with death. This is a prospective cohort study including Australian participants aged ≥45 years with self-reported coronary heart disease (2006-2020). Self-reported PA (min/wk) and SB (h/d) were the exposures. Cardiac and all-cause death were the main outcomes. The cohort included 40 156 participants (mean age, 70.3 (SD, 10.3) years; 15 278 women [38%]). During a median follow-up of 11.1 (interquartile range, 6.2-14.4) years, 2497 cardiac and 12 240 all-cause deaths were recorded. Compared with no PA, a 20% to 30% lower risk of cardiac and all-cause death was associated with any level of PA. Walking and moderate to vigorous PA at 150 to 300 min/wk was associated with a 43% to 44% lower risk of cardiac death and 35% to 40% lower risk of all-cause death. Compared with ≥10.5 h/d of SB, participants who were sedentary for 7 to 10.4 h/d experienced an ≈25% reduced associated risk of cardiac and all-cause death. A 56% associated reduction in all-cause mortality risk was found if SB was limited to <3.4 h/d. If participants completed >150 min/wk moderate to vigorous PA and spent <7 h/d in SB, the associated risk of cardiac and all-cause death was reduced by ≈70%. All people with coronary heart disease should be encouraged to meet the PA guidelines and limit SB to <7 h/d, noting any increase in physical activity and decrease in SB is better than none to prevent premature death.

Comparative Profiles of the WATCHMAN™ and Amplatzer™ Cardiac Plug/Amplatzer™ Amulet™ Devices for Left Atrial Appendage Closure in Non-valvular Atrial Fibrillation: A Comprehensive Systematic Review and Meta-analysis.

Atrial fibrillation (AF) is a prevalent cardiac arrhythmia marked by irregular and frequent tachycardic rhythms in the atria, affecting 1%-2% of the general population. The WATCHMAN™ device from Boston Scientific (Marlborough, MA, USA) and the Amplatzer™ Amulet™ device from Abbott (Chicago, IL, USA) are two devices used globally for left atrial appendage closure (LAAC) in non-valvular AF. A systematic search was conducted in PubMed, the Cochrane Library, and Elsevier's ScienceDirect literature databases to identify studies comparing the WATCHMAN™ procedure with Amulet™ device implantation for LAAC in patients with AF. The analyses were conducted using the random-effects model. A total of 20 studies were identified, with 18 falling into the category of observational studies and 2 being randomized controlled trials. A total of 6310 participants were included in this meta-analysis, with 3198 individuals (50.68%) assigned to the WATCHMAN™ procedure group and 3112 individuals (49.32%) allocated to the Amplatzer™ Cardiac Plug (ACP) group. The analysis revealed a higher risk of stroke associated with the WATCHMAN™ technique (relative risk [RR], 1.14), albeit without statistical significance. Conversely, the WATCHMAN™ approach led to a significantly lower risk of cardiac death (RR, 0.44; P = .04). Notably, the risks of all-cause mortality (RR, 0.89; 95% confidence interval [CI], 0.73-1.08; I 2 = 0%; P = .25) and major bleeding (RR, 0.93; 95% CI, 0.65-1.33; I 2 = 31%; P = .70) were clinically reduced with the WATCHMAN™ procedure, although statistical significance was not achieved. Compared to Amulet™ device implantation, WATCHMAN™ device implantation decreased the risk of cardiac mortality, while the risks of stroke, systemic embolism, all-cause mortality, and major bleeding were not statistically significant.

Intravascular imaging-guided percutaneous coronary intervention in patients with acute myocardial infarction and cardiogenic shock

Introduction and objectivesThere are no clinical data on the efficacy of intravascular imaging-guided percutaneous coronary intervention (PCI) compared with angiography-guided PCI in patients with acute myocardial infarction (AMI) and cardiogenic shock. The current study sought to evaluate the impact of intravascular imaging-guided PCI in patients with AMI and cardiogenic shock. MethodsAmong a total of 28 732 patients from the nationwide pooled registry of KAMIR-NIH (November, 2011 to December, 2015) and KAMIR-V (January, 2016 to June, 2020), we selected a total of 1833 patients (6.4%) with AMI and cardiogenic shock who underwent PCI of the culprit vessel. The primary endpoint was major adverse cardiovascular events (MACE) at 1 year, a composite of cardiac death, myocardial infarction, repeat revascularization, and definite or probable stent thrombosis. ResultsAmong the study population, 375 patients (20.5%) underwent intravascular imaging-guided PCI and 1458 patients (79.5%) underwent angiography-guided PCI. Intravascular imaging-guided PCI was associated with a significantly lower risk of 1-year MACE than angiography-guided PCI (19.5% vs 28.2%; HR, 0.59; 95%CI, 0.45-0.77; P<.001), mainly driven by a lower risk of cardiac death (13.7% vs 24.0%; adjusted HR, 0.53; 95%CI, 0.39-0.72; P<.001). These results were consistent in propensity score matching (HR, 0.68; 95%CI, 0.46-0.99), inverse probability weighting (HR, 0.61; 95%CI, 0.45-0.83), and Bayesian analysis (Odds ratio, 0.66, 95% credible interval, 0.49-0.88). ConclusionsIn AMI patients with cardiogenic shock, intravascular imaging-guided PCI was associated with a lower risk of MACE at 1-year than angiography-guided PCI, mainly driven by the lower risk of cardiac death.

Intravascular Imaging in Patients With Complex Coronary Lesions and Chronic Kidney Disease

As patients with chronic kidney disease (CKD) are more likely to have complex coronary lesions, intravascular imaging guidance in percutaneous coronary intervention (PCI) for this population could be potentially beneficial. To investigate whether the outcomes of intravascular imaging-guided procedural optimization would be different according to the presence of CKD. This was a prespecified substudy of RENOVATE-COMPLEX-PCI, a recently published multicenter randomized clinical trial in Korea studying the benefits of intravascular imaging for complex coronary lesions. Patients with complex coronary lesions, with or without CKD, were enrolled between May 2018 and May 2021. Data were analyzed from January to June 2023. PCI in each group was done either under the guidance of intravascular imaging or angiography alone. The primary end point was target vessel failure (TVF) at the 3-year point, defined as a composite of cardiac death, target vessel-related myocardial infarction, or clinically driven target vessel revascularization. A total of 1639 patients (1300 male [79.3%]) treated with PCI for complex coronary lesions were stratified into CKD (296 participants) and non-CKD (1343 participants) groups. The mean (SD) age of each group was 70.3 (9.4) and 64.5 (10.1) years, and mean (SD) estimated serum creatinine was 2.9 (5.3) and 0.8 (0.2) mg/dL for CKD and non-CKD groups, respectively. Intravascular imaging-guided revascularization was associated with significantly lower incidence of the primary end point compared with angiography-guided revascularization in both CKD (13.3% vs 23.3%; hazard ratio [HR], 0.51; 95% CI, 0.27-0.93; P = .03) and non-CKD (6.4% vs 9.9%; HR, 0.66; 95% CI, 0.44-0.99; P = .05) groups. The significantly lower incidence of the primary end point was mainly associated with the lower risk of cardiac death or target vessel-related myocardial infarction (9.4% vs 22.2%; HR, 0.39; 95% CI, 0.20-0.76; P = .006) in the CKD group and by target vessel revascularization (3.0% vs 5.5%; HR, 0.55; 95% CI, 0.30-0.99; P = .05) in the non-CKD group. Those with a glomerular filtration rate of at least 30 mL/min/1.73m2 and less than 60 ml/kg/1.73m2 showed the greatest benefit from imaging-guided complex PCI (8.8% vs 21.2%; HR, 0.28; 95% CI, 0.11-0.68; P = .02). In this prespecified cohort substudy of the Randomized Controlled Trial of Intravascular Imaging Guidance versus Angiography-Guidance on Clinical Outcomes After Complex Percutaneous Coronary Intervention trial, intravascular imaging guidance showed clinical benefit over angiography guidance in reducing the risk of TVF, regardless of the presence of CKD. The greatest benefits of imaging-guided complex PCI were observed in stage 3 CKD. ClinicalTrials.gov Identifier: NCT03381872.

Prognostic Impact of Operator Experience and IVUS Guidance on Long-Term Clinical Outcomes After Complex PCI

BackgroundAlthough consistent clinical data support intravascular ultrasound (IVUS) use during complex percutaneous coronary intervention (PCI), long-term follow-up outcomes on differential effects of IVUS according to operator experience are scarce. ObjectivesThe current study aimed to evaluate the influence of operator experience on lesion complexity, long-term clinical outcomes, and the interactions of IVUS guidance in patients undergoing complex PCI. MethodsA total of 6,005 patients who underwent PCI with drug-eluting stents for complex lesions were recruited from the institutional registry of Samsung Medical Center. The study population was stratified by the use of IVUS and operator experience (less experienced operator [lifetime independent experience with PCI ≤5 years] vs experienced operator). The primary endpoint was a composite of cardiac death or target vessel myocardial infarction (TVMI) up to 10 years. ResultsCompared with less experienced operators, experienced operators used IVUS more frequently (29.6% [1,128/3,805] vs 24.8% [546/2,200]; P < 0.001) and achieved a lower risk of cardiac death or TVMI (experienced vs less experienced, adjusted HR: 0.779; 95% CI: 0.663-0.915; P = 0.002). IVUS use was associated with a significantly lower risk of cardiac death or TVMI than angiography alone for less experienced operators (23.5% vs 11.4%; adjusted HR: 0.477; 95% CI: 0.337-0.673; P < 0.001) as well as experienced operators (18.0% vs 13.5%; adjusted HR: 0.747; 95% CI: 0.559-0.998; P = 0.048). There were significant interactions for the risk of cardiac death or TVMI between IVUS use and operator experience (P = 0.037). ConclusionsPCI by experienced operators and the use of IVUS during complex PCI were independently associated with lower long-term risks of cardiac death or TVMI. The beneficial effects of IVUS were more prominent for less experienced operators. (Prospective Percutaneous Coronary Intervention Registry [SMC-PCI]; NCT05624905)

E-9 | Intravascular Ultrasound Guided Percutaneous Coronary Intervention for Complex Calcified Lesion Requiring Rotational Atherectomy

Intravascular ultrasound (IVUS) is a very useful tool for accurate lesion assessment and optimal stent implantation in complex coronary intervention. We sought to evaluate the impact of IVUS guidance on percutaneous coronary intervention (PCI) using rotational atherectomy (RA) for complex calcified lesion. Five-hundred fourteen patients with calcified coronary artery disease who underwent PCI using RA and second-generation drug-eluting stent between January 2010 and October 2019 at 9 tertiary centers, from the ‘ROtational atherectomy in Calcified lesions in Korea (ROCK)’ registry, were included in this study. Primary endpoint was a composite of cardiac death, myocardial infarction or target vessel revascularization. Secondary endpoints included individual components of primary endpoint. Among the overall study population, IVUS was used in 242 patients (47.1%) during complex PCI using RA. The IVUS-guided PCI group had higher prevalences of accompanying left main disease (23.7% vs. 5.9%; p < 0.001) and left anterior descending artery as a target vessel (77.6% vs 68.1%; p=0.023), and more frequent uses of adjunctive post-dilatation (88.0% vs. 73.8%; p < 0.001), dual antiplatelet therapy (99.6% vs 94.1%; p<0.001) and beta blocker (75.4% vs 66.9%; p=0.04) at discharge, compared with the angiography-guided PCI group. During a median follow-up of 20 [9-39] months, MACE rate was not significantly different between the two groups (19.1% vs. 31.4%; hazard ratio (HR): 0.855; 95% confidence interval (CI): 0.530 to 1.377; p = 0.519). However, IVUS-guided PCI was associated with a significantly lower risk of cardiac death or MI compared with angiography-guided PCI (9.6% vs. 23.5%; HR: 0.478; 95% CI: 0.253 to 0.904; p=0.02). Multivariate analysis showed that IVUS guidance was independently associated with a lower risk of cardiac death or MI (adjusted HR: 0.414, 95% CI: 0.198–0.862; p=0.019). IVUS guidance should be considered when performing PCI with RA for complex calcified lesion.

Association between sick sinus syndrome and atrial fibrillation: A systematic review and meta-analysis

AimsSick sinus syndrome (SSS) and atrial fibrillation (AF) frequently coexist and show a bidirectional relationship. This systematic review and meta-analysis aimed to decipher the precise relationship between SSS and AF, further exploring and comparing different therapy strategies on the occurrence or progression of AF in patients with SSS. Methods and resultsA systematic literature search was conducted until November 2022. A total of 35 articles with 37,550 patients were included. Patients with SSS were associated with new-onset AF compared to those without SSS. Catheter ablation was associated with a lower risk of AF recurrence, AF progression, all-cause mortality, stroke and hospitalization of heart failure compared to pacemaker therapy. Regarding the different pacing strategies for SSS, VVI/VVIR has higher risk of new-onset AF than DDD/DDDR. No significant difference was found between AAI/AAIR and DDD/DDDR, as well as between DDD/DDDR and minimal ventricular pacing (MVP) for AF recurrence. AAI/AAIR was associated with higher risk of all-cause mortality when compared to DDD/DDDR, but lower risk of cardiac death when compared to DDD/DDDR. Right atrial septum pacing was associated with a similar risk of new-onset AF or AF recurrence compared to right atrial appendage pacing. ConclusionSSS is associated with a higher risk of AF. For patients with both SSS and AF, catheter ablation should be considered. This meta-analysis re-emphasizes that high percentage of ventricular pacing should be avoided in patients with SSS in order to decrease AF burden and mortality.

Myocardial Scar and Revascularization on Mortality in Ischemic Cardiomyopathy (from the Late Gadolinium Enhancement Cardiac Magnetic Resonance Study)

Myocardial viability test to guide revascularization remains uncertain in patients with ischemic cardiomyopathy. We evaluated the different impacts of revascularization on cardiac mortality according to the extent of myocardial scar assessed by cardiac magnetic resonance (CMR) with late gadolinium enhancement (LGE) in patients with ischemic cardiomyopathy. A total of 404 consecutive patients with significant coronary artery disease and an ejection fraction ≤35% were assessed by LGE-CMR before revascularization. Of them, 306 patients underwent revascularization and 98 patients received medical treatment alone. The primary outcome was cardiac death. During a median follow-up of 6.3years, cardiac death occurred in 158 patients (39.1%). Revascularization was associated with a significantly lower risk of cardiac death than medical treatment alone in the overall population (adjusted hazard ratio [aHR] 0.29, 95% confidence interval (CI) 0.19 to 0.45, p <0.001). There was a significant interaction between the number of segments with >75% transmural LGE and revascularization on the risk of cardiac death (p=0.037 for interaction). In patients with limited myocardial scar (<6 segments with >75% transmural LGE, n=354), revascularization had a significantly lower risk of cardiac death than medical treatment alone (aHR 0.24, 95% CI 0.15 to 0.37, p <0.001); in patients with extensive myocardial scar (≥6 segments with >75% transmural LGE, n=50), there was no significant difference between revascularization and medical treatment alone regarding the risk of cardiac death (aHR 1.33, 95% CI 0.46 to 3.80, p=0.60). In conclusion, the assessment of myocardial scar by LGE-CMR may be helpful in the decision-making process for revascularization in patients with ischemic cardiomyopathy.

Adverse cardiovascular, limb, and renal outcomes in patients with diabetes after peripheral artery disease revascularization treated with sodium glucose cotransporter 2 inhibitors versus dipeptidyl peptidase-4 inhibitors

AimsThe effectiveness and limb safety of sodium glucose co-transporter 2 inhibitors (SGLT2i) for patients with type-2 diabetes (T2D) who have received peripheral artery disease (PAD) revascularization are unknown.Methods and resultsIn this nationwide retrospective cohort study, we identified a total of 2,455 and 8,695 patients with T2D who had undergone PAD revascularization and received first prescriptions for SGLT2i and dipeptidyl peptidase-4 inhibitors (DPP4i), respectively, between May 1, 2016, and December 31, 2019. We used 1:1 propensity score matching (PSM) to balance covariates between the two study groups. Patients were followed up from the drug index date until the occurrence of specified outcomes, death, discontinuation of the index drug, or the end of the study period, whichever occurred first. After PSM, we observed that compared with DPP4i, SGLT2i were associated with comparable risks of ischemic stroke, acute myocardial infarction, and heart failure hospitalization but were associated with a lower risk of cardiac death (hazard ratio [HR]: 0.60; 95% confidence interval [CI]: 0.40–0.90]; p = 0.0126). Regarding major limb outcomes, SGLT2i were associated with comparable risks of repeated revascularization and lower limb amputation compared with DPP4i. SGLT2i were associated with a lower risk of composite renal outcomes (HR: 0.40; 95% CI: 0.27–0.59; p < 0.0001) compared with DPP4i.ConclusionIn a real-world study of patients with T2D who had undergone PAD revascularization, SGLT2i were associated with lower risks of cardiac death and composite renal outcomes but not associated with increased risks of adverse limb events compared with DPP4i.

Good coronary collateral circulation is not associated with better prognosis in patients with chronic total occlusion, regardless of treatment strategy

ObjectiveThis study aimed to assess the effects of coronary collateral circulation (CCC) on the prognosis of patients with chronic total occlusion (CTO) under different treatment strategies. MethodsWe analyzed a total of 1124 patients who were diagnosed with CTO and divided them into groups with good CCC (grade 2 to 3, n = 539) or poor CCC (grade 0 to 1, n = 531). The primary outcome was cardiac death during follow-up; the secondary outcome was major adverse cardiovascular events (MACEs). We also performed subgroup analyses in groups with and without CTO revascularization (CTO-R and CTO-NR, respectively), and sensitivity analyses excluding patients who received failed CTO-PCI to further investigate the effect of CCC. ResultsDuring a median follow-up duration of 23 months, we did not detect any significant differences between the good CCC group and the poor CCC group in terms of cardiac death (4.2% vs 4.1%; adjusted hazard ratio [HR], 1.01; 95% confidence interval [CI], 0.56–1.83; p = 0.970) and MACEs (23.6% vs 23.2%; adjusted HR, 1.07; 95% CI, 0.84–1.37; p = 0.590). Subgroup analyses according to CTO revascularization showed similar results. In addition, we observed no differences in sensitivity analyses when patients who received failed CTO-PCI were excluded. ConclusionGood CCC was not associated with a lower risk of cardiac death or MACEs among patients with CTO, regardless of whether the patients received CTO revascularization treatment.

Systematic Review and Network Meta-Analysis Comparing Bifurcation Techniques for Percutaneous Coronary Intervention.

BackgroundBifurcation lesions account for 20% of all percutaneous coronary interventions and represent a complex subset which are associated with lower procedural success and higher rates of restenosis. The ideal bifurcation technique, however, remains elusive.Methods and ResultsExtensive search of the literature was performed to pull data from randomized clinical trials that met predetermined inclusion criteria. Conventional meta‐analysis produced pooled relative risk (RR) and 95% CI of 2‐stent technique versus provisional stent on prespecified outcomes. Both frequentist and Bayesian network meta‐analyses were performed to compare bifurcation techniques. A total of 8318 patients were included from 29 randomized clinical trials. Conventional meta‐analysis showed no significant differences in all‐cause mortality, cardiac death, major adverse cardiac events, myocardial infarction, stent thrombosis, target lesion revascularization, and target vessel revascularization between 2‐stent techniques and provisional stenting. Frequentist network meta‐analysis revealed that double kissing crush was associated with lower cardiac death (RR, 0.57; 95% CI, 0.38–0.84), major adverse cardiac events (RR, 0.50; 95% CI, 0.39–0.64), myocardial infarction (RR, 0.60; 95% CI, 0.39–0.90), stent thrombosis (RR, 0.50; 95% CI, 0.28–0.88), target lesion revascularization, and target vessel revascularization when compared with provisional stenting. Double kissing crush was also superior to other 2‐stent techniques, including T‐stent or T and protrusion, dedicated bifurcation stent, and culotte.ConclusionsDouble kissing crush was associated with lower risk of cardiac death, major adverse cardiac events, myocardial infarction, stent thrombosis, target lesion revascularization, and target vessel revascularization compared with provisional stenting and was superior to other 2‐stent techniques. Superiority of 2‐stent strategy over provisional stenting was observed in subgroup meta‐analysis stratified to side branch lesion length ≥10 mm.

Use of intravascular ultrasound and long-term cardiac death or myocardial infarction in patients receiving current generation drug-eluting stents

Long-term follow-up data on differential effects of intravascular ultrasound (IVUS) according to lesion complexity are limited in patients undergoing percutaneous coronary intervention (PCI). The current study compared long-term clinical outcomes between IVUS-guided and angiography-guided PCI in patients with second-generation drug-eluting stents (DES). Between February 2008 and December 2015, 5488 patients undergoing PCI with second-generation DES were recruited from an institutional registry of Samsung Medical Center. The primary outcome was a composite of cardiac death or myocardial infarction (MI) during 46 months of median follow-up (interquartile range: 32–102 months). IVUS-guided PCI was performed in 979 patients (17.8%). IVUS-guided PCI was associated with a significantly lower risk of cardiac death or MI compared with angiography-guided PCI (5.7% vs. 12.9%, hazard ratio 0.408, 95% confidence interval 0.284–0.587, p < 0.001). Results were consistent after propensity score matching analysis with 801 matched pairs. In subgroup analysis, there was no significant interaction between lesion complexity (defined by complex procedures, Pinteraction = 0.819, ACC/AHA lesion classification, Pinteraction = 0.401 or SYNTAX score, Pinteraction = 0.149) and use of IVUS for risk of cardiac death or MI. IVUS-guided second-generation DES implantation was associated with a significantly lower long-term risk of cardiac death or MI compared with angiography guidance, regardless of lesion complexity.

Percutaneous Coronary Intervention vs. Coronary Artery Bypass Grafting for Treating In-Stent Restenosis in Unprotected-Left Main: LM-DRAGON-Registry.

BackgroundData regarding management of patients with unprotected left main coronary artery in-stent restenosis (LM-ISR) are scarce.ObjectivesThis study investigated the safety and effectiveness of percutaneous coronary intervention (PCI) vs. coronary artery bypass grafting (CABG) for the treatment of unprotected LM-ISR.MethodsConsecutive patients who underwent PCI or CABG for unprotected LM-ISR were enrolled. The primary endpoint was a composite of major adverse cardiac and cerebrovascular events (MACCE), defined as cardiac death, myocardial infarction (MI), target vessel revascularization (TVR), and stroke.ResultsA total of 305 patients were enrolled, of which 203(66.6%) underwent PCI and 102(33.4%) underwent CABG. At 30-day follow-up, a lower risk of cardiac death was observed in the PCI group, compared with the CABG-treated group (2.1% vs. 7.1%, HR 3.48, 95%CI 1.01–11.8, p = 0.04). At a median of 3.5 years [interquartile range (IQR) 1.3–5.5] follow-up, MACCE occurred in 27.7% vs. 29.6% (HR 0.82, 95%CI 0.52–1.32, p = 0.43) in PCI- and CABG-treated patients, respectively. There were no significant differences between PCI and CABG in cardiac death (9.9% vs. 18.4%; HR 1.56, 95%CI 0.81–3.00, p = 0.18), MI (7.9% vs. 5.1%, HR 0.44, 95%CI 0.15–1.27, p = 0.13), or stroke (2.1% vs. 4.1%, HR 1.79, 95%CI 0.45–7.16, p = 0.41). TVR was more frequently needed in the PCI group (15.2% vs. 6.1%, HR 0.35, 95%CI 0.15–0.85, p = 0.02).ConclusionsThis analysis of patients with LM-ISR revealed a lower incidence of cardiac death in PCI compared with CABG in short-term follow-up. During the long-term follow-up, no differences in MACCE were observed, but patients treated with CABG less often required TVR.Visual overviewA visual overview is available for this article.Registrationhttps://www.clinicaltrials.gov; Unique identifier: NCT04968977.

Role of Intravascular Ultrasound‐Guided Percutaneous Coronary Intervention in Optimizing Outcomes in Acute Myocardial Infarction

BackgroundThe role of intravascular ultrasound (IVUS)‐guided percutaneous coronary intervention (PCI) is still unclear in patients with acute myocardial infarction acute myocardial infarction. This study aimed to evaluate the long‐term impact of IVUS‐guided PCI in patients with acute myocardial infarction.Methods and ResultsAmong a total of 13 104 patients with acute myocardial infarction, enrolled in the Korea Acute Myocardial Infarction Registry‐National Institutes of Health, we selected patients who underwent PCI with second‐generation drug‐eluting stent implantation. The primary outcome was the risk of target lesion failure at 3 years. Among the study population, 1887 patients (21.0%) underwent IVUS‐guidance, and 7120 patients (79.0%) underwent angiography‐guidance for second‐generation drug‐eluting stent implantation. IVUS‐guided PCI was associated with a significantly lower risk of target lesion failure at 3 years (4.8% versus 8.0%; hazard ratio [HR], 0.59; 95% CI, 0.47 to 0.73; P<0.001) compared with angiography‐guided PCI. The difference was driven mainly by a lower risk of cardiac death and target vessel myocardial infarction. The results were consistent after confounder adjustment by multiple sensitivity analyses. Moreover, quartile analysis of volume of IVUS use showed that higher IVUS use was associated with a decreased risk of 3‐year target lesion failure (adjusted HR, 0.58; 95% CI, 0.45 to 0.75; P<0.001 for quartile 1 versus 4; P<0.001 for trend comparison across all quartiles).ConclusionsIn patients with acute myocardial infarction who underwent PCI with second‐generation drug‐eluting stent implantation, the use of IVUS guidance was associated with a significant reduction in 3‐year target lesion failure, mainly driven by hard end points, such as cardiac death and target vessel myocardial infarction.

Abstract 12061: Myocardial Scar and Revascularization on Mortality in Ischemic Cardiomyopathy:Late Gadolinium Enhancement Cardiac Magnetic Resonance Study

Background: Myocardial viability test to guide revascularization remains uncertain in patients with ischemic cardiomyopathy. We aimed to evaluate the different impacts of revascularization on cardiac mortality according to the extent of myocardial scar assessed by cardiac magnetic resonance with late gadolinium enhancement (LGE-CMR) in patients with ischemic cardiomyopathy. Methods: A total of 404 consecutive patients with significant coronary artery disease and an ejection fraction ≤35% were assessed by LGE-CMR before revascularization. Of them, 306 patients underwent revascularization and 98 patients received medical treatment alone. The primary outcome was cardiac death. Results: During a median follow-up of 6.3 years, cardiac death occurred in 158 (39.1%) patients. Revascularization was associated with a significantly lower risk of cardiac death than medical treatment alone in the overall population (adjusted hazard ratio [aHR], 0.29; 95% confidence interval [CI], 0.19-0.45; P &lt; 0.001). There was a significant interaction between the number of segments with 76%-100% transmural LGE and revascularization on the risk of cardiac death (P = 0.037 for interaction). In patients with limited myocardial scar (&lt; 6 segments with 76%-100% transmural LGE, N = 354), revascularization had a significantly lower risk of cardiac death than medical treatment alone (aHR, 0.24; 95% CI, 0.15-0.37; P &lt; 0.001); in patients with extensive myocardial scar (≥ 6 segments with 76-100% transmural LGE, N = 50), there was no significant difference between revascularization and medical treatment alone regarding the risk of cardiac death (aHR, 1.33; 95% CI, 0.46-3.80; P = 0.60). Conclusions: Assessment of myocardial scar by LGE-CMR may be helpful in the decision-making process for revascularization in patients with ischemic cardiomyopathy.

Drug-Eluting or Bare-Metal Stents for Left Anterior Descending or Left Main Coronary Artery Revascularization.

BackgroundNew‐generation drug‐eluting stents (DES) reduce target‐vessel revascularization compared with bare‐metal stents (BMS), and recent data suggest that DES have the potential to decrease the risk of myocardial infarction and cardiovascular mortality. We evaluated the treatment effect of DES versus BMS according to the target artery (left anterior descending [LAD] and/or left main [LM] versus other territories [no‐LAD/LM]).Methods and ResultsThe Coronary Stent Trialist (CST) Collaboration gathered individual patient data of randomized trials of DES versus BMS for the treatment of coronary artery disease. The primary outcome was the composite of cardiac death or myocardial infarction. Hazard ratios (HRs) with 95% CIs were derived from a 1‐stage individual patient data meta‐analysis. We included 26 024 patients across 19 trials: 13 650 (52.4%) in the LAD/LM and 12 373 (47.6%) in the no‐LAD/LM group. At 6‐year follow‐up, there was strong evidence that the treatment effect of DES versus BMS depended on the target vessel (P‐interaction=0.024). Compared with BMS, DES reduced the risk of cardiac death or myocardial infarction to a greater extent in the LAD/LM (HR, 0.76; 95% CI, 0.68–0.85) than in the no‐LAD/LM territories (HR, 0.93; 95% CI, 0.83–1.05). This benefit was driven by a lower risk of cardiac death (HR, 0.83; 95% CI, 0.70–0.98) and myocardial infarction (HR, 0.74; 95% CI, 0.65–0.85) in patients with LAD/LM disease randomized to DES. An interaction (P=0.004) was also found for all‐cause mortality with patients with LAD/LM disease deriving benefit from DES (HR, 0.86; 95% CI, 0.76–0.97).ConclusionsAs compared with BMS, new‐generation DES were associated with sustained reduction in the composite of cardiac death or myocardial infarction if used for the treatment of LAD or left main coronary stenoses.RegistrationURL: https://www.crd.york.ac.uk/PROSPERO; Unique identifier: CRD42017060520.

Surgical aortic valve replacement and left ventricular remodeling: Survival and sex-related differences.

To analyze how left ventricular (LV) remodeling and hypertrophy geometry evolve after surgical aortic valve replacement (SAVR) in octogenarian patients, and identify potential sex-related differences and implications for long-term outcomes. In 170 patients with aortic stenosis ([AS], age 80±4years, 59% women), hypertrophy geometry and remodeling (LV index) were reanalyzed one year post-SAVR. The six-year outcomes were evaluated. Pre-SAVR, 65% of the women and 38.6% of the men (P<.001) showed adaptive remodeling. Concentric hypertrophy was prevalent in adaptive remodeling, and mixed and dilated hypertrophy were more prevalent in maladaptive remodeling. At one year, the remodeling patterns and sex distribution were similar to those observed pre-SAVR, but the LV index decreased in women and increased in men (P<.0001). Women with adaptive remodeling had a higher incidence of persistent concentric hypertrophy with higher LV filling pressures. Long-term survival was better in women and worse in men with adaptive remodeling (P=.039). Men with adaptive remodeling and men with concentric hypertrophy had the highest risk of cardiac death. This risk was similar between sexes for patients with maladaptive remodeling and dilated hypertrophy. Women with LV ejection fraction >55% had a lower risk of cardiac death than men. The long-term outcomes of SAVR differ between sexes in older patients with AS and adaptive LV remodeling. The LV index facilitates studying the pathways of adaptation to AS. The follow-up shifts help explain the sex differences in long-term outcomes post-SAVR. Concentric hypertrophy is associated with the highest risk of cardiac death in men.

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.