Management Of Coronary Artery Disease Research Articles

Device profile of the XIENCE V and XIENCE Sierra stents for the treatment of coronary artery disease: an overview of safety and efficacy

ABSTRACT Introduction: Coronary angioplasty with the use of stents transformed the percutaneous treatment of coronary artery disease. First-generation drug-eluting stents reduced the risk of restenosis but carried a threat of late stent thrombosis. Second-generation drug-eluting stents resolved these issues and have proven so far very good safety and efficacy performance. Areas covered: This article aims to describe the new XIENCE® Sierra everolimus-eluting coronary stent system, to analyze the available data so far with regards to the safety, the effectiveness, and the overall clinical performance of the device and to seek future perspectives. Expert opinion: XIENCE® Sierra everolimus-eluting coronary stent carries all the positive features of the precursor stents of the XIENCE® family and brings an ultra-low crossing profile which further increases deliverability and flexibility. CoCr-everolimus-eluting stents are among if not the most extensively investigated coronary stents and have demonstrated over the years a consistently remarkable low risk of acute, subacute, late, and very late stent thrombosis and are considered a trustworthy device in the interventional management of complex coronary artery disease.

Oral antiplatelet therapy in the elderly undergoing percutaneous coronary intervention: an umbrella review.

Percutaneous coronary intervention has become a mainstay in the management of coronary artery disease. While initially advanced age was considered a relative contraindication to invasive management of coronary artery disease, current cardiovascular practice stands solidly on an early invasive approach for elderly patients, typically based on radial access and drug-eluting stent implantation. Since the advent of coronary stents, oral antiplatelet therapy has proved crucial to maximize the benefits and minimize the risks of stenting, and this holds even truer in older patients rather than in younger ones. Indeed, the elderly is typically at higher risk of thrombotic events as well as bleeding complications, and thus careful decision making must be exercised to prescribe the most appropriate antiplatelet regimen. We thus conducted an umbrella review with scoping purposes on oral antiplatelet therapy in elderly patients undergoing percutaneous coronary intervention, retrieving 8 pertinent systematic reviews. We found that, while several drugs are available, ranging from aspirin to cilostazol, clopidogrel, dipyridamole, prasugrel, ticagrelor, and ticlopidine, most commonly a dual antiplatelet therapy comprising aspirin and a P2Y12 inhibitor is recommended, with subtle adjustments for pretreatment, loading, dose, duration, escalation or de-escalation, with the potential adjunct in selected patients of novel oral anticoagulants. Indeed, a flexible and individualized approach to oral antiplatelet therapy in elderly patients undergoing percutaneous coronary intervention is paramount, factoring patient features (exploiting thrombotic, bleeding and frailty scores), triage (including when appropriate non-invasive assessment of anatomic and functional significance of coronary artery disease), angiographic and other invasive imaging features, interventional technique, stent choice, rehabilitation, and secondary prevention.

Is ischemia a disease or syndrome, the cause of angina, and now even a trial?

The clinical manifestations of myocardial ischemia are protean in nature and include a variable combination of typical or atypical angina symptoms, electrocardiographic changes, noninvasive findings of regional wall motion abnormalities, and reversible scintigraphic perfusion defects—the changes of which, importantly, may or may not be of epicardial coronary origin. Thus, mounting evidence indicates that the presence or absence of atherosclerotic coronary artery disease (CAD) should no longer be considered a surrogate marker for myocardial ischemia, as suggested by the high prevalence of minor or absent coronary obstruction among patients with proven myocardial ischemia. Whereas the management of CAD has been largely predicated on the plausible assumption that flow-limiting obstructions of the epicardial coronary arteries are the proximate cause of both angina and myocardial ischemia, there is scant evidence from many randomized trials and several meta-analyses that treating epicardial coronary obstructions in patients with stable CAD, particularly with percutaneous coronary intervention (PCI), reduces mortality and morbidity, as compared with optimal medical therapy (OMT). A crucial scientific question for which evidence has been lacking is whether more severe and extensive myocardial ischemia is the driver of adverse cardiovascular outcomes and whether an invasive strategy with myocardial revascularization would be superior to OMT alone in such patients. The results of the recent ISCHEMIA trial (International Study of Comparative Health Effectiveness with Medical and Invasive Approaches), however, have failed to show—even in this higher-risk CAD subset—any incremental clinical benefit of revascularization as compared with OMT alone on cardiac event reduction.

Cardiac Computed Tomography for Comprehensive Coronary Assessment: Beyond Diagnosis of Anatomic Stenosis.

Cardiac computed tomography angiography (CCTA) has evolved into a versatile imaging modality that can depict atherosclerosis burden, determine functional significance of a stenotic lesion, and guide the management and treatment of stable coronary artery disease.1 With newer-generation scanners, diagnostic CCTA can be obtained in the majority of patients with a very acceptable radiation dose. We discuss the ability of CCTA to provide comprehensive assessment of a patient with suspected CAD, including functional techniques of stress-rest myocardial perfusion assessment using a vasodilator and a purely post-processing approach that assesses fractional flow reserve derived by CCTA. In addition, recent data validated the role of CCTA in managing stable patients with chest pain and suspected CAD, serving as a gatekeeper for invasive coronary angiogram as well as optimizing the preprocedural planning of percutaneous coronary revascularization and coronary artery bypass surgery.

Metabolic Syndrome and Framingham Risk Score in Coronary Artery Disease Cases

Metabolic syndrome is a group of simultaneous conditions that expanding your risk of heart disease, stroke, and type 2 diabetes. These conditions include increased blood pressure, high glucose level, and abundance muscle versus fat around the abdomen or triglyceride levels. The objective of the study is to demographic, biochemical, obesity indices and angiographic profile (severity of CAD) of patients with coronary artery disease (CAD). A prospective and observational study involving a number of 971 patients who had undergone coronary angiogram (CAG) for the 18-month CAD assessment. In present study about half of population had significant abnormality on coronary angiogram. Amongst abnormal coronary angiogram about 50% of patients had single vessel disease. The FRS had positive correlation with severity of coronary artery disease and waist circumference. FRS and metabolic syndrome had critical contribution as score and risk factors with presence of and severity of CAD. To conclude it was suggested to incorporate FRS and components of metabolic syndrome for better management and risk stratification of coronary artery disease at large.

Prediction of Changes in Adherence to Secondary Prevention Among Patients With Coronary Artery Disease.

Healthcare providers are concerned about adherence to provider recommendations in coronary artery disease management. Seeking patient-related factors influencing changes in adherence over time is necessary for formulating suitable intervention measures-especially among diverse populations. To explore whether health literacy, self-efficacy, and disease knowledge predict changes in adherence over time (between baseline and 3 months) to secondary prevention recommendations for Chinese coronary artery disease patients. A longitudinal study was performed for 662 patients following percutaneous coronary intervention in China. Self-reported data were collected at baseline during hospitalization and at a 3-month telephone follow-up. Variables included demographics, health literacy, self-efficacy, disease knowledge, and adherence to secondary prevention recommendations for medication taking and a heart-healthy lifestyle. Multinomial logistic regression identified predictors of adherence changes over time. Patients were categorized into three groups: sustained/declined to nonadherence between baseline and 3 months, improved to adherence, and sustained adherence. The number of patients in sustained/declined to nonadherence group was small. Absence of stents predicted sustained/declined to nonadherence to medication and lifestyle over time. Health literacy was not associated with adherence changes over time. Higher self-efficacy scores were associated with lower likelihood of sustained/declined to nonadherence to a healthy lifestyle over time, whereas higher disease knowledge scores were associated with higher sustained/declined to nonadherence to medication. Adherence to secondary prevention 3 months after discharge was relatively good in Chinese patients with coronary artery disease who received percutaneous coronary intervention. Absence of stents and lower self-efficacy can predict the poor adherence changes, which should be considered in formulating follow-up care.

Impact of machine-learning CT-derived fractional flow reserve for the diagnosis and management of coronary artery disease in the randomized CRESCENT trials.

To determine the potential impact of on-site CT-derived fractional flow reserve (CT-FFR) on the diagnostic efficiency and effectiveness of coronary CT angiography (CCTA) in patients with obstructive coronary artery disease (CAD) on CCTA. This observational cohort study included patients with suspected CAD who had been randomized to cardiac CT in the CRESCENT I and II trials. On-site CT-FFR was blindly performed in all patients with at least one ≥ 50% stenosis onCCTA and no exclusion criteria for CT-FFR. We retrospectively assessed the effect of adding CT-FFR to the CT protocol in patients with a stenosis ≥ 50% on CCTA in terms of diagnostic effectiveness, i.e., the number of additional tests required to determine the final diagnosis, reclassification of the initial management strategy, and invasive coronary angiography (ICA) efficiency, i.e., ICA rate without ≥ 50% CAD. Fifty-three patients out of the 372 patients (14%) had at least one ≥ 50% stenosis on CCTA of whom 42/53 patients (79%) had no exclusion criteria for CT-FFR. CT-FFR showed a hemodynamically significant stenosis (≤ 0.80) in 27/53 patients (51%). The availability of CT-FFR would have reduced the number of patients requiring additional testing by 57%-points compared with CCTA alone (37/53 vs. 7/53, p < 0.001). The initial management strategy would have changed for 30 patients (57%, p < 0.001). Reserving ICA for patients with a CT-FFR ≤ 0.80 would have reduced the number of ICA following CCTA by 13%-points (p = 0.016). Implementation of on-site CT-FFR may change management and improve diagnostic efficiency and effectiveness in patients with obstructive CAD on CCTA. • The availability of on-site CT-FFR in the diagnostic evaluation of patients with obstructive CAD on CCTA would have significantly reduced the number of patients requiring additional testing compared with CCTA alone. • The implementation of on-site CT-FFR would have changed the initial management strategy significantly in the patients with obstructive CAD on CCTA. • Restricting ICA to patients with a positive CT-FFR would have significantly reduced the ICA rate in patients with obstructive CAD on CCTA.

PCI PROVIDES COSTLY MORTALITY REDUCTIONS FOR BREAST CANCER PATIENTS: PROPENSITY SCORE AND MACHINE LEARNING AUGMENTED NATIONALLY REPRESENTATIVE CASE-CONTROL STUDY OF 30 MILLION+ HOSPITALIZATIONS

Since the optimal management of coronary artery disease (CAD) and breast cancer is unknown, we sought to conduct the first known nationally representative study of mortality and cost effectiveness for breast cancer and percutaneous coronary interventions (PCI). Backward propagation neural network

NATIONAL TRENDS IN HOSPITALIZATIONS, MORTALITY AND COST OF CARE AMONG ACUTE MYOCARDIAL INFARCTION PATIENTS IN THE UNITED STATES: NATIONWIDE INPATIENT SAMPLE FROM 2001 TO 2014

Despite the advances in the management of coronary artery disease, acute myocardial infarction (AMI) has remained a significant health problem. While various factors including but not limited to demographics, socio-economic, environmental, and health-care facility utilization may impact the

Dual Antiplatelet Therapy in Coronary Artery Disease: Comparison Between ACC/AHA 2016 and ESC 2017 Guidelines.

Dual antiplatelet therapy (DAPT) is integral to the management of coronary artery disease (CAD) but there remains uncertainty as to the optimal approach for balancing an individual’s risk of atherothrombotic events versus their risk of bleeding complications. A myriad of clinical trials have investigated how factors such as antiplatelet selection or duration of treatment can affect outcomes in both stable CAD and acute coronary syndromes. To aid clinicians in the challenge of applying trial findings to the circumstances of individual patients, the American College of Cardiology/American Heart Association and European Society of Cardiology have released focused updates on prescribing DAPT in CAD. While the two guidelines agree on many issues, there are some differences in the recommendations. This article highlights those differences and provides comment on their aetiology.

Surgical Outcome of Coronary Artery Bypass Graft in Patients with Previous Coronary Stenting

Background: With the advancement of percutaneous coronary interventions, patients are presenting to coronary artery bypass grafting (CABG) older, with several co-morbidities and with prior coronary stenting. The outcome of surgery after stenting continues to be debated. We evaluated the surgical outcome of coronary artery bypass grafting in patients with previous coronary stenting. Methods: This prospective cohort study included 50 patients with previous coronary stent who underwent CABG between February 2016 and June 2017. Thirty-eight patients were males (76%), and the mean age was 57.66±8.81 years. The mean ejection fraction was 41.43±9.25%. Forty-six patients (92%) had previous one stent, and 4 patients (8%) had 2 stents. Results: Nineteen patients had in-stent restenosis (38%), and 31 patients had new lesions (62%). Seven patients had lesions distal to the site of the stent (14%). The mean cardiopulmonary bypass time was 102.66±25.34 minutes. Two patients needed an intraoperative intra-aortic pump and four in the ICU. Five patients (10%) developed acute myocardial infarction. Operative mortality occurred in 4 patients (8%); one patient (2%) had an acute renal failure. Ejection fraction at 6 months post-discharge showed an increase compared to the preoperative value (41.43±9.25%- 44.78±6.99%, P= 0.013). Mortality occurred more frequently in patients with IABP and in patients who had MI and renal failure. Mortality was not associated with in-stent stenosis. Conclusion: Coronary artery bypass grafting in patients with prior coronary stenting could be associated with increased morbidity and mortality. Proper management of coronary artery disease is essential to decrease the risk of future intervention.

A CASE STUDY ON CLINICAL PHARMACIST INTERVENTIONS IN THE MANAGEMENT OF DIABETES COMPLICATED CORONARY ARTERY DISEASE IN HEALTH-CARE PRACTICE

Objective: The objective of the study was to assess the clinical pharmacist interventions in the management of diabetes complicated coronary artery disease.&#x0D; Methods: In the present study, a case history of a 55-year-old female was suffering from diabetes with coronary artery disease was taken. The case was collected from the cardiology outpatient department in a tertiary care hospital. The case was analyzed from 1 to 3 months. The initial visit to the end of final visit her laboratory parameters was examined at the laboratory.&#x0D; Results: The test report of electrocardiogram revealed sinus rhythm. The patient was advised for an echocardiogram which confirmed coronary artery disease. The patient was subjected to a coronary angiogram, which revealed the presence of double-vessel disease. Her ankle-brachial index study test revealed peripheral artery disease. The patient was diagnosed with coronary artery disease, and she was prescribed with regular medications. The patient was monitored for 1-week duration and prescribed with coronary artery disease medications to normalize the condition. The patient was improved with the treatment and advised for regular follow-ups.&#x0D; Conclusion: The study concludes that there was an imperative need for regular health screening by the physician associated clinical pharmacist care services with an effective treatment modality that can reduce the coronary artery disease incidences in this patient.

Spotlight on Impactful Research: Utilization of Aspirin and Statin in Management of Coronary Artery Disease in Patients With Cirrhosis Undergoing Liver Transplant Evaluation.

http://aasldpubs.onlinelibrary.wiley.com/hub/journal/10.1002/(ISSN)2046-2484/video/15-2-reading-frankul a video presentation of this article http://aasldpubs.onlinelibrary.wiley.com/hub/journal/10.1002/(ISSN)2046-2484/video/15-2-interview-frenette an interview with the author Answer questions and earn https://www.wileyhealthlearning.com/Activity/7036138/disclaimerspopup.aspx.

The Two-Edged Sword of Shared Clinical Decision-Making in the Post-ISCHEMIA World of Stable Coronary Artery Disease Management

The Two-Edged Sword of Shared Clinical Decision-Making in the Post-ISCHEMIA World of Stable Coronary Artery Disease Management

Two-year outcomes among stable high-risk patients following acute MI. Insights from a global registry in 25 countries

BackgroundEvidence is lacking on long-term outcomes in unselected patients surviving the first year following myocardial infarction (MI). Methods and resultsThe TIGRIS (long-Term rIsk, clinical manaGement and healthcare Resource utilization of stable coronary artery dISease in post-myocardial infarction patients) prospective registry enrolled 9176 eligible patients aged ≥50 years, 1–3 years post-MI, from 25 countries. All had ≥1 risk factor: age ≥ 65 years, diabetes mellitus, second prior MI, multivessel coronary artery disease, chronic kidney disease (CKD). Primary outcome was a composite of MI, unstable angina with urgent revascularization, stroke, or all-cause death at 2-year follow-up. Bleeding requiring hospitalization was also recorded. 9027 patients (98.4%) provided follow-up data: the primary outcome occurred in 621 (7.0%), all-cause mortality in 295 (3.3%), and bleeding in 109 (1.2%) patients. Events accrued linearly over time. In multivariable analyses, qualifying risk factors were associated with increased risk of primary outcome (incidence rate ratio [RR] per 100 patient-years [95% confidence interval]): CKD 2.06 (1.66, 2.55), second prior MI 1.71 (1.38, 2.10), diabetes mellitus 1.63 (1.39, 1.92), age ≥ 65 years 1.53 (1.28, 1.83), and multivessel disease 1.24 (1.05, 1.48). Risk of bleeding events was greater in older patients (vs <65 years) 65–74 years 2.68 (1.53, 4.70), ≥75 years 4.62 (2.57, 8.28), and those with CKD 1.99 (1.18, 3.35). ConclusionIn stable patients recruited 1–3 years post-MI, recurrent cardiovascular and bleeding events accrued linearly over 2 years. Factors independently predictive of ischemic and bleeding events were identified, providing a context for deciding on treatment options.

Usefulness of Routine Fractional Flow Reserve for Clinical Management of Coronary Artery Disease in Patients With Diabetes

Approximately one-third of patients considered for coronary revascularization have diabetes, which is a major determinant of clinical outcomes, often influencing the choice of the revascularization strategy. The usefulness of fractional flow reserve (FFR) to guide treatment in this population is understudied and has been questioned. To evaluate the usefulness and rate of major adverse cardiovascular events (MACE) of integrating FFR in management decisions for patients with diabetes who undergo coronary angiography. This cross-sectional study used data from the PRIME-FFR study derived from the merger of the POST-IT study (Portuguese Study on the Evaluation of FFR-Guided Treatment of Coronary Disease [March 2012-November 2013]) and R3F study (French Study of FFR Integrated Multicenter Registries Implementation of FFR in Routine Practice [October 2008-June 2010]), 2 prospective multicenter registries that shared a common design. A population of all-comers for whom angiography disclosed ambiguous lesions was analyzed for rates, patterns, and outcomes associated with management reclassification, including revascularization deferral, in patients with vs without diabetes. Data analysis was performed from June to August 2018. Death from any cause, myocardial infarction, or unplanned revascularization (MACE) at 1 year. Among 1983 patients (1503 [77%] male; mean [SD] age, 65 [10] years), 701 had diabetes, and FFR was performed for 1.4 lesions per patient (58.2% of lesions in the left anterior descending artery; mean [SD] stenosis, 56% [11%]; mean [SD] FFR, 0.81 [0.01]). Reclassification by FFR was high and similar in patients with and without diabetes (41.2% vs 37.5%, P = .13), but reclassification from medical treatment to revascularization was more frequent in the former (142 of 342 [41.5%] vs 230 of 730 [31.5%], P = .001). There was no statistical difference between the 1-year rates of MACE in reclassified (9.7%) and nonreclassified patients (12.0%) (P = .37). Among patients with diabetes, FFR-based deferral identified patients with a lower risk of MACE at 12 months (25 of 296 [8.4%]) compared with those undergoing revascularization (47 of 257 [13.1%]) (P = .04), and the rate was of the same magnitude of the observed rate among deferred patients without diabetes (7.9%, P = .87). Status of insulin treatment had no association with outcomes. Patients (6.6% of the population) in whom FFR was disregarded had the highest MACE rates regardless of diabetes status. Routine integration of FFR for the management of coronary artery disease in patients with diabetes may be associated with a high rate of treatment reclassification. Management strategies guided by FFR, including revascularization deferral, may be useful for patients with diabetes.

Infarct Zone: a Novel Platform for Exosome Trade in Cardiac Tissue Regeneration.

The global incidence of coronary artery diseases (CADs), especially myocardial infarction (MI), has drastically increased in recent years. Even though the conventional therapies have improved the outcomes, the post-MI complications and the increased rate of recurrence among the survivors are still alarming. Molecular events associated with the pathogenesis and the adaptive responses of the surviving myocardium are largely unknown. Focus on exosome-mediated signaling for cell-cell/matrix communications at the infarct zone reflects an emerging opportunity in cardiac regeneration. Also, cardiac tissue engineering provides promising insights for the next generation of therapeutic approaches in the management of CADs. In this article, we critically reviewed the current understanding on the biology of cardiac exosomes, therapeutic potential of exosomes, and recent developments in cardiac tissue engineering and discussed novel translational approaches based on tissue engineering and exosomes for cardiac regeneration and CADs.

Short commentary on Studies of Aerobic capacity and Role of High ORAC Value in CAD Patients

Coronary artery disease (CAD) is a growing epidemic across the globe. There is ever-evolving research to decode aetiology, diagnosis, treatment and management of CAD. Cardiovascular diseases especially the coronary artery disease is the leading cause of mortality and morbidity in India with the prevalence rate increasing by the year. It is a progressive disease characterised by the accumulation of lipids, inflammation and plaque formation. The risk factors include smoking, diabetes mellitus, hypertension, obesity and high cholesterol.

Therapeutic Role of Natural Agents in the Management of Coronary Artery Disease: A Review.

This review delineates the potential of naturally occurring substances for coronary artery disease (CAD), mainly coronary ischemia and its management, with their active constituents and probable mechanisms of action. As per the WHO, statistical incidence of CAD has increased in several countries. The number of coronary events worldwide has been increasing, and may increase even more in the near future. Meanwhile, increased sedentary behavior and poor diet will encourage the prevalence of CAD worldwide. As far as treatment is concerned, current conventional therapies have limitations due to their increased adverse events. The current approach to the management of CAD has certain lacunas that need to be overcome. Thus, new therapeutic options should be explored using traditional literature and current scientific data on natural products. The present review article deals with current knowledge associated with naturally occurring substances for the management of CAD.

Management of Coronary Artery Disease in the Setting of Transcatheter Aortic Valve Replacement.

Aortic stenosis and coronary artery disease (CAD) frequently co-exist, as they share a common pathophysiology and risk factors. Due to lack of randomised controlled trials (RCTs) and exclusion of significant CAD in transcatheter aortic valve replacement (TAVR) trials, the optimal method of revascularisation of CAD in patients undergoing TAVR remains unknown. Observational studies and meta-analyses have shown varied results in outcomes for patients with CAD undergoing TAVR, and no significant difference in post-TAVR outcomes in patients who underwent revascularisation either prior to or during TAVR versus those who did not. However, some observational studies have shown that patients with lower residual SYNTAX score (rSS) post-revascularisation have better outcomes post-TAVR compared to those with higher rSS. RCTs are needed to clearly understand whether revascularisation is beneficial in these patients. Until then, management of CAD in patients undergoing TAVR must be individualised based on discussion with the heart team.