Multivessel Coronary Artery Disease Research Articles

EARLY RESULTS OF MINIMALLY INVASIVE CORONARY ARTERY BYPASS GRAFTING

Abstract Coronary artery bypass grafting (CABG) is the benchmark in elective revascularization for Coronary Artery Disease (CAD), particularly for complex or multivessel CAD, left main coronary involvement, diabetes, or impaired heart function. Traditional CABG, via median sternotomy using cardiopulmonary bypass (CPB), has limitations like CPB–related morbidity and sternal complications. Alternatives like Minimally Invasive Cardiac Surgery (MICS CABG) and Hybrid Revascularization (HR) aim to address these drawbacks. We present a series of 215 consecutive patients (mean age 67±9 years, 27.9% females, EuroSCORE II 1.5±1.3%) between 2017–2023 who underwent elective minimally invasive surgical revascularization. Among the cohort, 164 (76.3%) had Minimally Invasive Direct Coronary Artery Bypass (MIDCAB) via anterolateral left mini–thoracotomy (ALMT) at the fifth intercostal space (IS), with 140 (85.4%) receiving a single left internal thoracic artery (LITA) graft to the left anterior descending (LAD) artery and 24 (14.6%) an additional distal anastomosis. Thirty–four (20.7%) had HR via percutaneous coronary intervention (PCI) on the right coronary artery (RCA). Of the total cohort, 35/215 patients (16.3%) underwent multivessel MICS CABG via ALMT, with mean 2.3±0.5 distal anastomoses using LITA, right ITA, radial artery, or saphenous vein. Heart manipulation was via a subxiphoid device. Four MICS CABG patients (11.4%) had HR. More than half of MICS CABG cases were performed with planned peripheral CPB, without cross–clamping the Aorta. Of the total cohort, 16/215 patients (7.4%) received MICS CABG in an endoscopic fashion, using 3D thoracoscopy for LITA and RITA harvesting via bilateral ports in the 2nd, 3rd, and 4th IS, employing peripheral CPB and aortic clamping by Chitwood clamp at the second IS, with cardioplegia delivery via a 4 cm right anterior MT. Distal anastomoses were performed via left anterior MT, with easy subxiphoid manipulation of the emptied heart. Transit time flowmetry was used in all cases. Conversion to sternotomy was needed in 3 cases, all were MIDCAB. Thirty–day mortality was 1.4%, median ventilation was 4 [2–5] hours, and Intensive Care Unit–stay was 1 [1–2] days. All patients received graft evaluation via computerized tomography before hospital discharge. Mean follow–up was 2.9±1.9 years (max 5 years), with no deaths and 4 (1.9%) requiring follow–up PCI. MICS CABG is a promising future technique for heart revascularization by dedicated teams.

A REAL–WORLD PROTOCOL OF EARLY USE OF TRIPLE LIPID LOWERING THERAPY WITH I–PCSK9

Abstract Aim We evaluated the feasibility of an early triple lipid lowering therapy (LLT) with PCSK9 inhibitors in patients with acute coronary syndromes (ACS). Methods In this multicenter experience, we consecutively enrolled ACS patients from July to November 2023. The prescribed LLT was evaluated at discharge. Triple therapy with a high–intensity statin plus ezetimibe and PCSK9i was recommended in the following cases: patients already on statin or statin/ezetimibe therapy with LDL–C values > 70 mg/dl; patients not on LLT at admission with LDL–C values > 70 mg/dl and at least one of diabetes mellitus (DM), multivessel coronary artery disease (MV) or peripheral arterial disease (PAD); patients not on LLT at the time of admission and LDL–C values > 140 mg/dl even in the absence of DM, MV or PAD. A six–month follow–up was planned to determine LDL–C target attainment, compliance, side e!ects, and cardiovascular events. Results We consecutively enrolled 264 patients, 95% of whom were discharged with high–intensity statin plus ezetimibe and 29% discharged with in–hospital addition of PCSK9i (triple therapy). Of the 77 patients discharged in triple LLT, the median age was 71.4 years, 71% were male, 42% were current smokers, DM was present in 19%, and 48% had history of hypertension. The diagnosis at admission was ST–Elevation Myocardial Infarction in 66.2%, Non–ST–Elevation Myocardial Infarction in 29.5%, and unstable angina in 4.3% of cases; 63% of patients had history of coronary artery disease and 6.8% had history of peripheral artery disease (PAD); 19.6% were already on at least one statin therapy and the median LDL–C value at admission was 128 mg/dl. Conclusions In conclusion, the use of an early and strong lipid lowering approach in very high risk patients with in–hospital or at discharge PCSK9i administration is feasible and safe. The complete results of six–months follow–up and LDL–C values will be available for the congress.

Understanding Perioperative Acute Myocardial Ischemia Following Coronary Artery Bypass Grafting.

Surgical revascularization and coronary artery bypass grafting are often pursued as treatment for obstructive coronary artery disease. Despite trends of increased referrals for complex percutaneous coronary intervention, surgical revascularization often remains the standard of care for patients with multivessel or complex coronary artery disease. Myocardial ischemia during the perioperative and postoperative periods during coronary artery bypass grafting remains a challenge. Nuanced consideration is necessary to decide on interventions that include conservative management and percutaneous or repeat surgical revascularization.

CARDIOGENIC SHOCK IN A PATIENT WITH SEVERE AORTIC VALVE STENOSIS AND MULTIVESSEL CORONARY DISEASE: ADVANCED THERAPEUTIC STRATEGIES

Abstract We describe a case of a 58 years old man. He was referred to emergency room for episodes of vomiting and epigastric pain for about a week. Upon admission he was confused with systolic–diastolic blood pressure values ​​70/40 mmHg, heart rate 120 bpm, sinus rhythm. pO2 was 80 mmHg and SO2 in air 97%. Lactate values 10, blood sugar > 300 mg/dl. The electrocardiogram showed sinus tachycardia with the results of antero–septal necrosis and incomplete left bundle branch block. The fast echocardiogram showed a dilated left ventricle with severe depression of the ejection fraction (EF about 10–15%), severe low flow–low gradient aortic valve stenosis (AVA bidimensional was approximately 0.9 cm²), severe mitral valve insufficiency due to a dual mechanism. The dimension of Inferior vena cava was 1.5 cm, collapsible. There was thrombotic stratification in the apex of the left ventricle and VA coupling was 2. The patient was admitted to the ICU with stage C cardiogenic shock according to SCAI classification. We found a value of PVC 3 mmHg. After fluide challenge there was an increase in blood pressure values to 100/60 mmHg. Noradrenaline vasopressor was started and subsequently a low dose of adrenaline. Blood pressure values maintained around 90/60 mmHg and undergo a sudden drop after increasing the dosage of the vasopressor. Diuresis was approximately 50 ml/h, lactates clear completely after approximately 4 hours. After 6 hours, due to a new sudden reduction in blood pressure, the patient was referred for IABP and coronary angiography control. In the context of multivessel coronary artery disease and cardiogenic shock he was therefore a candidate for urgent cardiac surgery of aortic valve replacement, by–pass and mitral anulovalvuloplasty. This case gave us the opportunity to analyze how to proceed in such a critical conditions with the below conclusions: a) the choice of vasopressors and inotropes is limited in case of severe aortic valve stenosis b) the presence of left ventricular intracavitary thrombosis limits the choice of ventricular assistance system c) in case of cardiogenic shock and severe aortic valve stenosis the patient must be a candidate for valve replacement surgery as soon as possible.

A rare case of right coronary artery dissection during routine left heart catheterization

Percutaneous coronary intervention (PCI) is an effective method for coronary revascularization, however, alongside its benefits, it can be accompanied by complications. Catheter induced coronary artery dissection (CICAD) is rare and the consequences can be devastating if left untreated. The incidence has been reported to be as low as 0.1%. Also, propagation of the dissection to the aortic root remains uncommon. The mechanism of dissection is related to mechanical injury to the arterial wall during manipulation with the catheter or wire. It may also occur due to injection of contrast, stenting or balloon dilation. Timely recognition is important in these cases to facilitate optimal patient outcomes which is usually accomplished with stenting. Herein, we report a rare case of a 68-year-old female with multivessel coronary artery disease who presented for routine left heart catheterization and developed catheter induced right coronary artery (RCA) dissection with propagation towards the aortic root which was treated with stenting and watchful waiting.

Staged versus immediate complete vessel revascularization in patients presenting with ST-segment elevation myocardial infarction: a systematic review and meta-analysis

Abstract Funding Acknowledgements None. Introduction In patients presenting with acute coronary syndrome (ACS) ST-segment elevation myocardial infarction (STEMI), percutaneous coronary intervention (PCI) is the preferred modality of reperfusion. However, these patients may also have multivessel coronary artery disease (CAD) on coronary angiography which is associated with higher risk of mortality. Current guidelines recommend complete revascularization in STEMI with multivessel CAD, however this poses a high risk for major acute cardiovascular events (MACE). Other available reperfusion strategies include staged vessel revascularization. This meta-analysis aims to determine if staged vessel revascularization can be a better mode of reperfusion strategy in patients with STEMI with multivessel CAD. Methods A comprehensive search of randomized controlled trials (RCT) was conducted with the use of staged versus immediate complete vessel revascularization in patients with STEMI. Outcome measures to assess the effectiveness of these techniques were all-cause mortality, MACE and target vessel revascularization. The analyses were done using random effects analysis model by mantel-haenszel statistical method via Review Manager V5.4. Results There were five studies included in the meta-analysis with 1,483 subjects analyzed. There was 26% less risk of all-cause mortality (RR 0.74 [95% CI: 0.41-1.31]) and 6% less risk for MACE (RR 0.94 [95% CI: 0.58-1.52]) in staged revascularization compared to immediate complete revascularization. In terms of target-vessel revascularization there was no statistical difference between the two treatment strategies (RR 1.02 [95% CI: 0.57-1.83]). Conclusion Staged and immediate complete vessel revascularization have similar rates of target-vessel revascularization among patients presenting with STEMI. However, staged vessel revascularization showed lower rates of all-cause mortality and MACE, which suggest that this treatment strategy may be a preferable type of revascularization in patients presenting with STEMI with multivessel CAD.

Improved Early Outcomes With Off-Pump Coronary Artery Bypass Grafting in Patients With Left Ventricular Dysfunction: A Systematic Review and Meta-Analysis.

The ongoing debate surrounding coronary artery bypass grafting (CABG) with or without cardiopulmonary bypass persists, particularly in individuals with left ventricular dysfunction. The objective of this study was to evaluate the safety and efficacy of these 2 strategies through a comprehensive meta-analysis of existing studies. A systematic search of PubMed, EMBASE, Web of Science, and the Cochrane Central Registry was conducted from inception to July 2023. The primary focus was on studies comparing on-pump versus off-pump CABG as the primary treatment for multivessel coronary artery disease in patients with left ventricular dysfunction (ejection fraction ≤40%), with mortality as the primary outcome. The meta-analysis included 26 studies with a total of 35,863 patients. The results revealed a significant reduction in mortality risk [risk ratio (RR), 0.75; 95% confidence interval (CI), 0.60-0.93; P = 0.009] and other perioperative morbidities associated with off-pump CABG. These included stroke (RR, 0.67; 95% CI, 0.54-0.82; P = 0.0002), myocardial infarction (RR, 0.74; 95% CI, 0.56-0.97; P = 0.03), pulmonary complications (RR, 0.71; 95% CI, 0.55-0.92; P = 0.010), postoperative transfusion (RR, 0.70; 95% CI, 0.55-0.88; P = 0.002), neurological dysfunction (RR, 0.80; 95% CI, 0.64-1.00; P = 0.05), infection (RR, 0.74; 95% CI, 0.56-0.97; P = 0.03), renal failure (RR, 0.79; 95% CI, 0.67-0.95; P = 0.010), and reoperation for bleeding (RR, 0.66; 95% CI, 0.52-0.84; P = 0.0006). However, no significant difference was observed between the 2 groups regarding postoperative atrial fibrillation (RR, 0.97; 95% CI, 0.84-1.12; P = 0.69). In conclusion, off-pump CABG demonstrates a lower perioperative mortality risk and improved overall early outcomes compared with on-pump techniques in individuals with reduced left ventricular function.

Drug Coated Balloon vs. Drug Eluting Stent in Multiculprit Primary Percutaneous Revascularization

Background: Patients presenting with ST-elevation myocardial infarction (STEMI) and undergoing primary percutaneous coronary intervention (PCI) frequently face multivessel coronary artery disease (CAD). The optimal interventional approach remains debated. Objective: To systematically review and analyze the effectiveness and safety of drug-coated balloons (DCB) versus drug-eluting stents (DES) in multiculprit primary PCI through a randomized controlled trial. Methods: This prospective, single-center, randomized controlled trial included 100 patients with STEMI and multivessel CAD at Lady Reading Hospital Peshawar from April 2023 to March 2024. Patients aged 18 years or older requiring revascularization of two or more culprit lesions were randomized into two groups: one received DCBs and the other DES. Exclusions were based on contraindications to dual antiplatelet therapy, allergies to study drugs, bleeding disorders, or life expectancy under one year. Results: Each group comprised 50 patients. The prevalence of hypertension (56% in DCB vs. 60% in DES, p=0.68) and diabetes (36% in DCB vs. 40% in DES, p=0.72) was similar. TVR rates were 10% for DCB and 8% for DES (p=0.45). MACE rates were 14% for DCB and 12% for DES (p=0.37). Conclusion: The study supports the use of DCB as an alternative to DES in specific clinical scenarios, emphasizing the need for tailored treatment decisions based on individual patient and lesion characteristics.

Performance of the left ventricular myocardium in patients with a negative test result during exercise stress echocardiography

Aim. To determine the possibility of identifying patients with significant coronary artery disease (CAD) by evaluation of the left ventricular (LV) myocardial work indicators by constructing pressure-strain loops despite a negative test result during exercise stress echocardiography. Materials and methods. The study included 79 patients with suspected or previously confirmed CAD, of which 47 (59%) men, who had a negative test result during exercise stress echocardiography on the treadmill. Global work index (GWI), global constructive work (GCW), global wasted work (GWW) and global work efficiency (GWE) were evaluated using the technique of constructing pressure-strain loops at rest and at peak exercise. Results. With similar systolic blood pressure and LV ejection fraction at peak exercise between the control group and the group of patients with single-vessel CAD, there was revealed significant difference in GWI, GCW and GWE at peak exercise. In patients with multi-vessel CAD, GWI and GCW also significantly differed from the control group at peak exercise. Conclusion. The evaluation of LV myocardial work indicators may be recommended for a more accurate diagnosis of CAD in negative or unreliable test results during exercise stress echocardiography.

A-21 | Association of Complete Revascularization with Safety and Outcomes in Elderly Patients with Multi-Vessel Coronary Artery Disease: A Systematic Review and Meta-Analysis

A-21 | Association of Complete Revascularization with Safety and Outcomes in Elderly Patients with Multi-Vessel Coronary Artery Disease: A Systematic Review and Meta-Analysis

OR6-1 | Association of Complete Revascularization with Mortality in Elderly Patients with Multi-Vessel Coronary Artery Disease: A Systematic Review and Meta-Analysis

OR6-1 | Association of Complete Revascularization with Mortality in Elderly Patients with Multi-Vessel Coronary Artery Disease: A Systematic Review and Meta-Analysis

Complete revascularization based on angiography derived fractional flow reserve versus incomplete revascularization in patients with ST-segment elevation myocardial infarction.

Nearly half of ST-segment elevation myocardial infarction (STEMI) patients present with significant multivessel coronary artery disease, they are at high risk of subsequent adverse events. Whether complete revascularization guided by coronary angiography-derived fractional flow reserve (caFFR) further reduces such events risk is not fully investigated. In this study, 367 consecutive STEMI patients who underwent successful primary percutaneous coronary intervention (PCI) were enrolled. caFFR of all three coronary vessels were measured, including 367 culprit vessels and 703 non-culprit vessels. Complete revascularization was defined as post-PCI caFFR > 0.8 of all three coronary vessels. The primary endpoint was major adverse cardiovascular events (MACE, a composite of cardiovascular death, non-fatal recurrent myocardial infarction, ischemia-driven revascularization and non-fatal stroke/transient ischemic attacks) during follow-up. At a median follow-up of 3.8 years, MACE had occurred in 39 patients of the 220 (17.7%) in the complete revascularization group as compared with 49 patients of the 131 (37.4%) in the incomplete revascularization group (hazard ratio [HR] 1.9; 95% confidence interval [CI] 1.2-3.0; p = 0.005). The incomplete revascularization in culprit vessels evaluated by caFFR showed the highest risk for MACE occurrence. In STEMI patients with multivessel coronary artery disease, incomplete revascularization based on caFFR might contribute to identifying patients at high-risk.

Infarct-related artery only revascularization versus multi-vessel revascularization for patients with Killip I-IV acute myocardial infarction and multivessel disease

Background The optimal revascularization strategy for non-culprit vessels is still up for debate nowadays, particularly when it comes to individuals with different Killip classes. Therefore, the aim of our study was to investigate whether multivessel revascularization, as compared with infarct-related artery (IRA) alone revascularization, improves long-term prognosis in patients who have experienced an acute myocardial infarction (AMI) and have multivessel coronary artery disease (CAD). Methods A retrospective analysis was conducted on clinical data from 646 patients who presented with AMI and multivessel CAD at Beijing Chaoyang hospital between November 2014 and November 2020. Based on various revascularization strategies, patients were categorised into two groups: IRA-only revascularization (n = 416) and multivessel revascularization (n = 230). The primary endpoint was cardiovascular death. Results In the following 60.6 months (60.6 ± 23.9), the primary endpoint occurred in 3% of the multivessel revascularization group versus 9.6% in the IRA-only revascularization group (HR 0.284, CI 0.120–0.669, p = 0.002). For the Killip I-II patients (n = 533), the primary endpoint occurred in 2.6% of the multivessel revascularization group versus 9.5% in the IRA-only revascularization group (HR 0.236, CI 0.083–0.667, p = 0.003). For Killip III-IV patients (n = 113), there was no significance differences in the primary endpoint. After using the inverse probability weighted method, the benefit of complete revascularization was consistently observed. Conclusions Multivessel revascularization significantly reduced the incidence of cardiovascular death for patients presenting with AMI and multivessel CAD, particularly for Killip I–II patients. There were no significant differences in the primary outcome across the groups of patients with Killip III–IV.

Long-term outcomes of myocardial revascularization in patients with multivessel coronary artery disease and comorbid pathology

<b>Objective:</b> To assess the long-term outcomes of myocardial revascularization in patients with multivessel coronary artery disease and varying degrees of comorbidity.<br /> <b>Materials and methods:</b> 406 patients with low and moderate Syntax scores (SS) (<33) underwent primary percutaneous coronary intervention (PCI) (n=200) with a drug-eluting stent, and coronary artery bypass grafting (CABG) (n=206). Patients were stratified by the Charlson Comorbidity Index (CCI) into 2 groups: 1) CCI ≤ 3(n=108/26.6%); 2) CCI ≥ 4(n=298/73.4%). The mean follow-up period was 9±1.9 years. The endpoints of the study were as follows: major adverse cardiac and cerebrovascular events (МАССЕ), a repeat revascularization, decreased left ventricular ejection fraction, and high SS in dynamics.<br /> <b>Results:</b> An increase in CCI of more than 4 points was significantly associated with the risk of developing a combination of MACCE (HR 1.3, CI 1.2 – 1.4, p<0.001), all-cause mortality (HR 1.3, CI 1.2 – 1.4, p<0.001), and cerebrovascular accidents (CVA) (HR 2.2, CI 1.4 – 3.4, p=0.001). Patients with CCI ≥4 required repeat revascularization more frequently after PCI than after CABG (HR 2.6, CI 1.8 – 3.7, p<0.001). Among patients with varying degrees of comorbidity, the risk of progression of coronary atherosclerosis (SS≥33) was higher after CABG compared with PCI.<br /> <b>Conclusion:</b> A CCI score of more than 4 points was associated with an increased risk of developing of MACCE, all-cause mortality, and CVA. Among patients with varying degrees of comorbidity, PCI and CABG did not demonstrate significant advantages in terms of MACCE.

Timing of fractional flow reserve-guided complete revascularization in patients with ST-segment elevation myocardial infarction with multivessel disease: Rationale and design of the OPTION-STEMI trial

Current guidelines recommend complete revascularization (CR) in hemodynamically stable patients with ST-segment elevation myocardial infarction (STEMI) and multivessel coronary artery disease (MVD). With regard to the timing of percutaneous coronary intervention (PCI) for non-infarct-related artery (non-IRA), recent randomized clinical trials have revealed that immediate CR was non-inferior to staged CR. However, the optimal timing of CR remains uncertain. The OPTION-STEMI trial compared immediate CR and in-hospital staged CR guided by fractional flow reserve (FFR) for intermediate stenosis of the non-IRA. The OPTION-STEMI is a multicenter, investigator-initiated, prospective, open-label, non-inferiority randomized clinical trial. The study included patients with at least one non-IRA lesion with ≥50% stenosis by visual estimation. Patients fulfilling the inclusion criteria were randomized into two groups at a 1:1 ratio: immediate CR (i.e., PCI for the non-IRA performed during primary angioplasty) or in-hospital staged CR. In the in-hospital staged CR group, PCI for non-IRA lesions was performed on another day during the index hospitalization. Non-IRA lesions with 50-69% stenosis by visual estimation were evaluated by FFR, whereas those with ≥70% stenosis were revascularized without FFR. The primary endpoint was the composite of all-cause death, non-fatal myocardial infarction, and all unplanned revascularization at 1 year after randomization. Enrolment began in December 2019 and was completed in January 2024. The follow-up for the primary endpoint will be completed in January 2025, and primary results will be available in the middle of 2025. The OPTION-STEMI is a multicenter, non-inferiority, randomized trial that evaluated the timing of in-hospital CR with the aid of FFR in patients with STEMI and MVD. URL: https://www. gov. Unique identifier: NCT04626882; and URL: https://cris.nih.go.kr. Unique identifier: KCT0004457.

Association between NT-proBNP level and the number of stents with major advanced cardiovascular events (MACE) in patients with multivessel coronary artery disease treated with percutaneous coronary intervention: A prospective cohort study

Association between NT-proBNP level and the number of stents with major advanced cardiovascular events (MACE) in patients with multivessel coronary artery disease treated with percutaneous coronary intervention: A prospective cohort study

FFR-Guided Complete or Culprit-Only PCI in Patients with Myocardial Infarction

BackgroundThe benefit of fractional flow reserve (FFR)–guided complete revascularization in patients with ST-segment elevation myocardial infarction (STEMI) and multivessel coronary artery disease remains unclear.MethodsIn this multinational, registry-based, randomized trial, we assigned patients with STEMI or very-high-risk non-STEMI (NSTEMI) and multivessel disease who were undergoing primary percutaneous coronary intervention (PCI) of the culprit lesion to receive either FFR-guided complete revascularization of nonculprit lesions or no further revascularization. The primary outcome was a composite of death from any cause, myocardial infarction, or unplanned revascularization. The two key secondary outcomes were a composite of death from any cause or myocardial infarction and unplanned revascularization.ResultsA total of 1542 patients underwent randomization, with 764 assigned to receive FFR-guided complete revascularization and 778 assigned to receive culprit-lesion-only PCI. At a median follow-up of 4.8 years (interquartile range, 4.3 to 5.2), a primary-outcome event had occurred in 145 patients (19.0%) in the complete-revascularization group and in 159 patients (20.4%) in the culprit-lesion-only group (hazard ratio, 0.93; 95% confidence interval [CI], 0.74 to 1.17; P=0.53). With respect to the secondary outcomes, no apparent between-group differences were observed in the composite of death from any cause or myocardial infarction (hazard ratio, 1.12; 95% CI, 0.87 to 1.44) or unplanned revascularization (hazard ratio, 0.76; 95% CI, 0.56 to 1.04). There were no apparent between-group differences in safety outcomes.ConclusionsAmong patients with STEMI or very-high-risk NSTEMI and multivessel coronary artery disease, FFR-guided complete revascularization was not shown to result in a lower risk of a composite of death from any cause, myocardial infarction, or unplanned revascularization than culprit-lesion-only PCI at 4.8 years. (Funded by the Swedish Research Council and others; FULL REVASC ClinicalTrials.gov number, NCT02862119.)

Apolipoprotein A1 Infusions and Cardiovascular Outcomes after Acute Myocardial Infarction

BackgroundCardiovascular events frequently recur after acute myocardial infarction, and low cholesterol efflux — a process mediated by apolipoprotein A1, which is the main protein in high-density lipoprotein — has been associated with an increased risk of cardiovascular events. CSL112 is human apolipoprotein A1 derived from plasma that increases cholesterol efflux capacity. Whether infusions of CSL112 can reduce the risk of recurrent cardiovascular events after acute myocardial infarction is unclear.MethodsWe conducted an international, double-blind, placebo-controlled trial involving patients with acute myocardial infarction, multivessel coronary artery disease, and additional cardiovascular risk factors. Patients were randomly assigned to receive either four weekly infusions of 6 g of CSL112 or matching placebo, with the first infusion administered within 5 days after the first medical contact for the acute myocardial infarction. The primary end point was a composite of myocardial infarction, stroke, or death from cardiovascular causes from randomization through 90 days of follow-up.ResultsA total of 18,219 patients were included in the trial (9112 in the CSL112 group and 9107 in the placebo group). There was no significant difference between the groups in the risk of a primary end-point event at 90 days of follow-up (439 patients [4.8%] in the CSL112 group vs. 472 patients [5.2%] in the placebo group; hazard ratio, 0.93; 95% confidence interval [CI], 0.81 to 1.05; P=0.24), at 180 days of follow-up (622 patients [6.9%] vs. 683 patients [7.6%]; hazard ratio, 0.91; 95% CI, 0.81 to 1.01), or at 365 days of follow-up (885 patients [9.8%] vs. 944 patients [10.5%]; hazard ratio, 0.93; 95% CI, 0.85 to 1.02). The percentage of patients with adverse events was similar in the two groups; a higher number of hypersensitivity events was reported in the CSL112 group.ConclusionsAmong patients with acute myocardial infarction, multivessel coronary artery disease, and additional cardiovascular risk factors, four weekly infusions of CSL112 did not result in a lower risk of myocardial infarction, stroke, or death from cardiovascular causes than placebo through 90 days. (Funded by CSL Behring; AEGIS-II ClinicalTrials.gov number, NCT03473223.)

Acute Coronary Syndrome Revascularization Strategies With Multivessel Coronary Artery Disease

In acute coronary syndromes (ACS), revascularization is the standard of care. However, trials comparing contemporary coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI) are limited. Optimal revascularization in patients with multi-vessel coronary artery disease (MV-CAD) presenting with ACS is unclear. This is a multi-centred, retrospective observational study from a large, hospital system in the United States. We abstracted data on patients with MV-CAD and ACS from 2018 to 2022 who underwent revascularization with PCI, CABG or medically managed (MM). We evaluated multivariate statistics comparing categorical variables and outcomes, including all-cause mortality (ACM) and myocardial infarction (MI) at 1 year. All logistic and Cox proportional-hazard models were balanced using inverse probability treatment weights accounting for age and sex. There were 295 CABG patients [median age 66 (IQR 59.7, 73.1); 73% male], 1,559 PCI patients [median age 68.3 (IQR 60, 76.6); 69.1% male], and 307 MM patients [median age 70 (60.9, 77.1) 74% male]. Patients revascularized with PCI had higher ACM at 1 year [14.1% vs. 5.1%; HR 2.4, CI (1.5, 3.8), p<0.001] and similar mortality to MM (13.4%). CABG also demonstrated reduced 1 year MI rate compared to PCI (1.7% vs 3.9%; HR 0.36, CI 0.21, 0.61, p=<0.001), with similar 1 year rate of MI to MM (3.9%). In conclusion, CABG, compared to PCI and MM, is associated with lower mortality, and repeat ACS events at 1 year in patients with ACS and MV-CAD.

Feasibility and Diagnostic Performance of Functional SYNTAX Score Derived From Dynamic CT Myocardial Perfusion Imaging.

Computed tomography (CT) fractional flow reserve (FFR)-derived functional SYNTAX score (FSSCT-FFR) is a valuable method for guiding treatment strategy in patients with multivessel coronary artery disease. Dynamic CT myocardial perfusion imaging (CT-MPI) demonstrates higher diagnostic accuracy than CT-FFR in identifying hemodynamically significant coronary artery disease. We aimed to evaluate the feasibility of CT-MPI-derived FSS (FSSCT-MPI) with reference to invasive FSS. In this retrospective study, patients with multivessel coronary artery disease who underwent dynamic CT-MPI+ coronary CT angiography and invasive coronary angiography or FFR within 4 weeks were consecutively included. Invasive (FSSinvasive) and noninvasive FSS (FSSCT-MPI and FSSCT-FFR) were calculated by an online calculator, which assigned points to lesions with hemodynamic significance (defined as FFRinvasive ≤0.80, invasive coronary angiography diameter stenosis ≥90%, CT-FFR ≤0.80, and myocardial ischemia on CT-MPI). Weighted κ value and net reclassification index were calculated to determine the consistency and incremental discriminatory power of FSSCT-MPI. Receiver operating characteristic curve analysis was used for the comparison of FSSCT-MPI and FSSCT-FFR in detecting intermediate- to high-risk patients. A total of 119 patients (96 men; 64.6±10.6 years) with 305 obstructive lesions were included. The average FSSCT-MPI, FSSCT-FFR, and FSSinvasive were 15.58±13.03, 16.18±13.30, and 13.11±12.22, respectively. The agreement on risk classification based on the FSSCT-MPI tertiles was good (weighted κ, 0.808). With reference to FSSinvasive, FSSCT-MPI correctly reclassified 27 (22.7%) patients from the intermediate- to high SYNTAX score group to the low-score group (net reclassification index, 0.30; P<0.001). In patients with severe calcification, FSSCT-MPI had better diagnostic value than FSSCT-FFR in detecting intermediate- to high-risk patients when compared with FSSinvasive (area under the curve, 0.976 versus 0.884; P<0.001). Noninvasive FSS derived from CT-MPI is feasible and has strong concordance with FSSinvasive. It allows accurate categorization of FSS in patients with multivessel coronary artery disease, in particular with severe calcification.