Major Adverse Cardiac And Cerebrovascular Events In Patients Research Articles

Treatment of symptomatic coronary artery disease in patients with end-stage renal disease on hemodialysis with paclitaxel-eluting TAXUS stent.

Percutaneous coronary intervention (PCI) utilizing drug-eluting stents is becoming a very common revascularization technique in the dialysis cohort; therefore, we sought to identify the impact of dialysis on outcomes in this group of patients. This is a multicenter registry comparing results of 290 patients (186 with normal kidney function, 104 on dialysis) who underwent PCI with exclusive use of paclitaxel-eluting TAXUS stent. The primary endpoint was an assessment of major adverse cardiac events (MACE) at 1- and 2-year observation. Mean follow-up was 23.3 ± 6.1 months. Results at 12 months showed: MACE 11.8% vs. 7.7% (P = not significant [ns]), composite major adverse cardiac and cerebrovascular events (MACCE) 12.4% vs. 11.5% (P = ns), all-cause death 2.7% vs. 8.6% (P < 0.05), cardiac death 2.7% vs. 1.9% (P = ns), target vessel revascularization (TVR) 9.1% vs. 6.7% (P = ns), acute myocardial infarction (AMI) 3.8% vs. 2.9% (P = ns), cerebrovascular events (CVA) 0.5% vs. 1.0% (P = ns); and results at 24 months showed: MACE 17.7% vs. 18.3% (P = ns), MACCE 21.5% vs. 26.0% (P = ns), all-cause death 4.3% vs. 14.4% (P < 0.01), cardiac death 3.2% vs. 1.9% (P = ns), TVR 14.0% vs. 16.3% (P = ns), AMI 5.4% vs. 5.8% (P = ns), CVA 3.2% vs. 2.9% (P = ns) for non-end-stage renal disease (ESRD) and dialysis group, respectively. Prior coronary artery bypass graft (CABG) was found to be single risk factor for MACE, TVR, and MACCE in patients with ESRD, while dialysis and prior CABG were found to be single risk factors for death in the entire population. PCI with TAXUS is a feasible procedure and presents promising results in dialysis-dependent patients.

Prior ischemic stroke is not associated with worse clinical outcomes in patients undergoing percutaneous coronary intervention.

Cerebrovascular accidents (CVAs) frequently coexist with coronary artery disease (CAD) and adversely affect prognosis in patients with CAD; however, fewer studies have investigated the role of prior ischemic stroke on the outcomes of percutaneous coronary intervention (PCI). The aim of this study was to determine the safety and effectiveness of PCI in patients with a prior ischemic stroke. A review of patients who underwent PCI between June 2003 and September 2005 (n=3893) at the Beijing Anzhen Hospital of Capital University of Medical Science, identified 295 PCI patients with a prior ischemic stroke (≥ 3 months) and 3598 patients without a prior stroke. To investigate whether prior history of an ischemic stroke was independently associated with increased risk of adverse PCI outcomes, prognostic parameters were analyzed using univariate analysis and Cox multivariate regression analysis. Propensity score analysis was then used to match the two subgroups of patients based on multiple factors known to impact cardiac outcome. Patients with a prior ischemic stroke had more frequent high-risk baseline characteristics (diabetes, hypertension, hyperlipidemia and prior myocardial infarction). No significant differences were found in the major adverse cardiac and cerebrovascular event (MACCEs) rates between the two groups (1.7% in the stroke group vs. 1.4% in the non-stroke group; p=0.06). Diabetes mellitus, triple vessel CAD, number of diseased vessels, chronic total occlusion and previous myocardial infarction were independent predictors of MACCE in patients with prior stroke undergoing PCI. This study demonstrates that, in daily clinical practice, PCI can be provided safely and with good results to patients with a prior ischemic stroke (≥ 3 months).

Cost‐effectiveness of percutaneous coronary intervention with drug‐eluting stents in patients with multivessel coronary artery disease compared to coronary artery bypass surgery five‐years after intervention

ObjectivesCost-effectiveness of percutaneous coronary intervention (PCI) using drug-eluting stents (DES), and coronary artery bypass surgery (CABG) was analyzed in patients with multivessel coronary artery disease over a 5-year follow-up.BackgroundDES implantation reducing revascularization rate and associated costs might be attractive for health economics as compared to CABG.MethodsConsecutive patients with multivessel DES-PCI (n = 114, 3.3 ± 1.2 DES/patient) or CABG (n = 85, 2.7 ± 0.9 grafts/patient) were included prospectively. Primary endpoint was cost-benefit of multivessel DES-PCI over CABG, and the incremental cost-effectiveness ratio (ICER) was calculated. Secondary endpoint was the incidence of major adverse cardiac and cerebrovascular events (MACCE), including acute myocardial infarction (AMI), all-cause death, revascularization, and stroke.ResultsDespite multiple uses for DES, in-hospital costs were significantly less for PCI than CABG, with 4551 €/patient difference between the groups. At 5-years, the overall costs remained higher for CABG patients (mean difference 5400 € between groups). Cost-effectiveness planes including all patients or subgroups of elderly patients, diabetic patients, or Syntax score >32 indicated that CABG is a more effective, more costly treatment mode for multivessel disease. At the 5-year follow-up, a higher incidence of MACCE (37.7% vs. 25.8%; log rank P = 0.048) and a trend towards more AMI/death/stroke (25.4% vs. 21.2%, log rank P = 0.359) was observed in PCI as compared to CABG. ICER indicated 45615 € or 126683 € to prevent one MACCE or AMI/death/stroke if CABG is performed.ConclusionsCost-effectiveness analysis of DES-PCI vs. CABG demonstrated that CABG is the most effective, but most costly, treatment for preventing MACCE in patients with multivessel disease. © 2014 Wiley Periodicals, Inc.

ASSA13-15-7 Drug-Eluting Stenting Versus Coronary Artery Bypass Graft For Unprotected Left Main Coronary Artery Disease: A Meta-Analysis Based on Time-To-Event Data from Randomised Controlled Trials

<h3>Objective</h3> Drug eluting stent (DES) with percutaneous coronary intervention is increasingly used to treat unprotected left main coronary artery (LMCA) disease. We undertook a meta analysis to assess outcomes for coronary artery bypass graft (CABG) and DES for unprotected LMCA disease. <h3>Methods</h3> We conducted a PubMed/EMBASE/CENTRAL search for RCTs evaluating CABG versus DES for unprotected LMCA. Primary outcome was survival. Secondary outcomes were major adverse cardiac and cerebrovascular event (MACCE) and target vessel revascularization (TVR). <h3>Results</h3> Four randomised controlled trials were identified evaluating a total of 2, 706 patients with unprotected LMCA. There was no significant difference between the CABG and DES groups in the risk for mortality (HR [hazard ratio]:0.76; 95% CI [confidence interval]: 0.47–1.23). The risks were lower for MACCE (0.78 [95% CI: 0.60–1.02]) and for TVR (0.73 [95% CI: 0.61–0.87]). <h3>Conclusions</h3> our meta-analysis of RCTs suggests that there are no significant differences in terms of survival and MACCE in patients with unprotected LMCA disease suitable for either DES or CABG, but CABG is superior to DES in reducing the incidence of TVR.

Revascularization in left main coronary artery disease: comparison of off-pump coronary artery bypass grafting vs percutaneous coronary intervention

There is no evidence for the increasing use of percutaneous coronary intervention (PCI) compared with surgery in patients with left main coronary artery (LMCA) disease. We compared the clinical outcomes of patients with LMCA disease who had undergone PCI with those of patients who had off-pump coronary artery bypass (OPCAB) grafting. From January 2001 to December 2009, 899 patients with LMCA disease were treated with OPCAB (n = 553) or PCI (n = 346). Analyses using propensity-score matching were performed to minimize the selection bias. We compared major adverse cardiac and cerebrovascular events (MACCE) including death, stroke, acute myocardial infarction and target-vessel revascularization. The median follow-up was 55.9 months. For the 159 propensity-matched pairs, the early mortality in the OPCAB group was lower than in the PCI group (0 vs 5%, the PCI group; P < 0.001). Overall survival at 8 years was similar between groups (88.6 ± 3.5%, the OPCAB group vs 85.8 ± 5.3%, the PCI group; P = 0.394). Freedom from MACCE at 8 years was significantly higher in the OPCAB than in the PCI group (83.9 ± 5.1 vs 60.2 ± 6.9%, P < 0.001). Although there was no intergroup difference in the risk of death [hazard ratio (HR) for the PCI group, 1.435; 95% confidence interval (CI), 0.62-3.31; P = 0.396], a significant difference was found in the risk of MACCE (HR for the PCI group, 4.193; 95% CI, 2.165-8.121; P < 0.001). This difference was primarily due to a higher risk of acute myocardial infarction (HR for the PCI group, 4.730; 95% CI, 0.99-22.63; P = 0.049) and higher rates of target-vessel revascularization (HR for the PCI group, 5.508; 95% CI, 1.87-16.22; P = 0.002). Compared with PCI, OPCAB is associated with a lower incidence of MACCE in patients with LMCA disease, determined mainly by the lower incidences of acute myocardial infarction and target-vessel revascularization. The incidence of stroke in the OPCAB group was similar to the PCI group.

Comparison of the Efficacy and Safety between Transradial and Transfemoral Percutaneous Coronary Intervention in Patients with Ischemic Heart Disease

Objective: The aim of this study was to evaluate the efficacy and safety of transradial percutaneous coronary intervention (TRI) com­ pared with transfemoral percutaneous coronary intervention (TFI) in patients with ischemic heart disease. Methods: We reviewed retrospectively the medical records including imaging data of the patients with ischemic heart disease who underwent TRI or TFI from January 2007 to December 2009 in Soonchunhyang University Seoul Hospital. We compared major ad­ verse cardiac and cerebrovascular events (MACCEs) including death, myocardial infarction, revascularization, stent thrombosis, and cerebrovascular accident during follow­up period. We also compared procedure related vascular complications including hema­ toma, arteriovenous fistula, pseudoaneurysm, and infection. Results: Total number of patients was 347 (256 patients of TRI and 91 patients of TFI). There were no significant differences in the rate of MACCEs between two groups. There were significantly less procedure ­related vascular complications in TRI group (3.1% vs. 11.0%, P = 0.010). Conclusion: TRI is as effective as TFI with no difference in the rate of MACCEs in patients with ischemic heart disease. TRI is superior to TFI in safety with reduction of vascular complications.

Left atrial volume predicts adverse cardiac and cerebrovascular events in patients with hypertrophic cardiomyopathy

AimsTo prospectively evaluate the relationship between left atrial volume (LAV) and the risk of clinical events in patients with hypertrophic cardiomyopathy (HCM).MethodsWe enrolled a total of 141 HCM patients with sinus rhythm and normal pump function, and 102 patients (73 men; mean age, 61 ± 13 years) who met inclusion criteria were followed for 30.8 ± 10.0 months. The patients were divided into two groups with or without major adverse cardiac and cerebrovascular events (MACCE), a composite of stroke, sudden death, and congestive heart failure. Detailed clinical and echocardiographic data were obtained.ResultsMACCE occurred in 24 patients (18 strokes, 4 congestive heart failure and 2 sudden deaths). Maximum LAV, minimum LAV, and LAV index (LAVI) corrected for body surface area (BSA) were significantly greater in patients with MACCE than those without MACCE (maximum LAV: 64.3 ± 25.0 vs. 51.9 ± 16.0 ml, p = 0.005; minimum LAV: 33.9 ± 15.1 vs. 26.2 ± 10.9 ml, p = 0.008; LAVI: 40.1 ± 15.4 vs. 31.5 ± 8.7 ml/mm2, p = 0.0009), while there were no differences in the other echocardiographic parameters.LAV/BSA of ≥ 40.4 ml/m2 to identify patients with cardiovascular complications with a sensitivity of 73% and a specificity of 88%.ConclusionLAVI may be an effective marker for detecting the risk of MACCE in patients with HCM and normal pump function.

The effect of pre-hospital statins therapy on incidence of in-hospital death and total MACCE in patients with PCI

To investigate the influence of preoperative statin therapy on rate of major adverse cardiac and cerebrovascular events (MACCE) during hospital stay after successful percutaneous coronary intervention (PCI). Review of patients who underwent PCI between June 2003 and September 2005 (n = 3893) at Beijing Anzhen Hospital of Capital University of Medical Science. (Group I, on statins, n = 3361; group II, not on statins, n = 532). To investigate if preoperative statin therapy was independently associated with the reduction in the risk of adverse postoperative outcomes after PCI. Prognostic factors were assessed using Cox multivariate regression analysis to determine if preoperative statin therapy was independently associated with a reduction in the risk of adverse postoperative outcomes. Our study demonstrated that preoperative statin therapy was not associated with a reduction in risk of mortality and overall MACCE during the hospital stay (0.3% vs. 0.4%; 1.4% vs. 1.2%P > 0.05, respectively).Compared with patients not receiving statins therapy, the hazard ratio for mortality in hospital was 0.738 (95% CI, 0.499-1.211, P = 0.229). Preoperative statin therapy did not reduce the risk of mortality and the rates of MACCE during the hospital stay after successful PCI. Cox multivariate regression analysis showed that independent prognostic parameters for mortality were Age, LVEF<50%, Triple vessel CAD, and DM (diabetes mellitus).

The clinical outcome of percutaneous treatment of bifurcation lesions in multivessel coronary artery disease with the sirolimus-eluting stent: insights from the Arterial Revascularization Therapies Study part II (ARTS II)

Little is known about the impact of treating bifurcations on the overall outcome of multivessel coronary artery disease treated with stenting. This analysis was made to investigate the 1 year clinical outcome of the treatment of bifurcation lesions using sirolimus-eluting stents (SES) in patients with multivessel disease. Among a total of 607 patients (2160 lesions) in the Arterial Revascularization Therapies Study part II (ARTS II), there were 324 patients in whom at least one bifurcation lesion was treated (465 lesions). Patients with bifurcations were compared with those without bifurcations in terms of baseline characteristics and major adverse cardiac and cerebrovascular events (MACCE). Patients with 'true' (200 patients) vs. 'partial' bifurcations (124 patients) and usage of a one- (263 patients) vs. two-stent strategy (61 patients) were also evaluated. The bifurcation group was associated with more complex lesion and procedural characteristics than the non-bifurcation group. However, there was no significant difference in 1 year MACCE rates between the bifurcation group and the non-bifurcation group (13.3 vs. 11.0%, P=0.46). MACCE in patients with true bifurcations was 13.0 vs. 13.7% for partial bifurcations (P=0.87) and 14.1 vs. 9.8% for one- vs. two-stent strategy (P=0.53). In this trial without angiographic follow-up, the presence of bifurcations did not affect 1 year outcomes after SES implantation. The outcomes in true vs. partial bifurcations and using one vs. two stents were similar when the treatment strategies were left to the operator's discretion.