Multivessel Disease Research Articles

Sex disparities in myocardial infarction related cardiogenic shock.

Women are underrepresented In cardiovascular disease research, constituting only 30 % of the cardiogenic shock (CS) population. Consequently, guidelines are mainly based on male patients. This study aims to comprehensively examine the sex-specific aspects of acute myocardial infarction (AMI)-related CS, encompassing presentation, treatment and outcomes. Patients with CS undergoing percutaneous coronary intervention (PCI) between 2017 and 2021 were identified using the national Netherlands Heart Registration. Mortality was assessed using the Kaplan Meier method, and logistic regression was performed to investigate differences in clinical management between sexes. Furthermore, a sensitivity analysis excluding patients with out-of-hospital cardiac arrest (OHCA) was conducted. Among 2274 patients, 614 (27 %) were female. Women were older (70 vs. 66 years, p < 0.001) and presented with longer symptom duration (> 3 h: 52 % vs. 37 %, p < 0.001). Men more often presented with multivessel disease (62 % vs. 56 %, p < 0.001), a prior myocardial infarction (23 % vs. 15 %, p < 0.001) and after an OHCA (46 % vs. 29 %, p < 0.001). A trend towards more usage of mechanical circulatory support in men was observed (adjusted OR 0.86, 95 % CI 0.67-1.09). Mortality, both adjusted and unadjusted, was not statistically different for men and women. Women with CS present with distinct clinical characteristics, including longer symptom duration, underscoring the importance of symptom recognition. Furthermore, men present at younger age and with more OHCA. Mortality in men and women was similar despite differences in presentation and clinical management.

Endoscopic-assisted, minimally invasive versus sternotomy total arterial multivessel bypass grafting.

This single center study compared the perioperative outcomes after total arterial multivessel revascularization through endoscopic-assisted, minimally invasive surgery compared to a conventional sternotomy approach. In this retrospective, propensity score matched (PSM) cohort study, a total of 740 patients were analyzed (Endo-CAB, N = 92; Sternotomy N = 648). After PSM (1:2 ratio), 73 Endo-CAB and 137 sternotomy patients were compared with an equal number of distal anastomoses (Endo-CAB 2.3 vs Sternotomy 2.4 anastomoses per patient, p = 0.082). We used "textbook outcome" as a patient-orientated outcome measure, defined as the absence of 30-day mortality, re-exploration for bleeding, postoperative ischaemia, cardiac tamponade, cerebrovascular events, wound infection, new onset arrhythmias, pneumonia, placement of chest drains and prolonged hospital stay (>7 days). Patients undergoing Endo-CAB had significantly more often a textbook outcome compared to the sternotomy group (78.1% vs 59.1%, p = 0.009). Endo-CAB patients had shorter hospital stay (4.0 vs 6.0 days, p < 0.001), less postoperative blood loss (360 vs 490 ml, p < 0.001) and a significant reduction of new onset postoperative atrial fibrillation (5.5% vs 17.5%, p = 0.015). Other postoperative outcomes were comparable for both groups. Total arterial Endo-CAB demonstrates excellent postoperative outcomes compared to a sternotomy approach for multivessel coronary artery disease. These findings provide a strong basis for further expanding the multivessel Endo-CAB program.

Comparative characteristics of minimally invasive and classical (median sternotomy) methods of coronary artery bypass grafting

Objective. To analyze the results and comparative characteristics of minimally invasive and classical coronary artery bypass grafting in multivessel coronary artery disease and the presence of critical stenosis. Materials and Methods. Over the past two years, the National Scientific Center of Surgery and Transplantation named after O. O. Shalimov performed mini­invasive coronary artery bypass grafting for multivessel lesions of the coronary arteries in 27 patients (group 1). The comparative study also included 27 patients operated on using the classical method (group 2). The average age of patients was (53.1 ± 3.9) years. There were 46 men (85.2%) and 8 women (14.8%). According to the main indicators, including the number of affected coronary arteries, age, physiological parameters, etc., the groups did not differ statistically significantly. The main methods of the study were coronary angiography, multislice computed tomography of the coronary arteries with 3D reconstruction of the architecture of the great vessels, chest and heart. Results. During the follow­up of patients in both groups for up to a year after the operation, no clinical manifestations of angina and heart failure were noted, which gives reason to state the good function of the shunts. Intra­ and postoperative complications in group 1 occurred in 2 patients: the need for conversion due to cardiac rhythm and hemodynamics (1) and repeated thoracotomy due to bleeding from the arterial shunt (1). In group 2, complications also occurred in 2 patients: sternal diastasis requiring sternoplasty (1) and surgical wound exudation requiring the installation of a vacuum device for 4 days with subsequent secondary suturing (1). Conclusions. Minimally invasive coronary artery bypass grafting is a safe method of myocardial revascularization in multivessel coronary artery disease and critical stenosis. The technique allows for rapid rehabilitation and shorter hospital stays, which is economically beneficial for the hospital. Minimally invasive coronary artery bypass grafting can be considered as an alternative to the classical method of coronary artery bypass grafting with midline sternotomy.

Outcomes of Urgent Coronary Artery Bypass Graft Surgery Following Non-ST Elevation Myocardial Infarction

Background: Non-ST elevation myocardial infarction (NSTEMI) significantly reduces patient survival, a condition that is essential for the optimization of results and the restoration of effective vascular flow multivessel coronary artery disease, Emergency coronary artery bypass grafting (CABG) is frequently contemplated. In the aftermath of NSTEMI, the objective of this investigation is to assess the results of urgent CABG, to prioritize risk stratification through the use of the Global Registry of Acute Coronary Events (GRACE) score Methods: An analysis of 60 consecutive patients who underwent emergent CABG following NSTEMI was conducted retrospectively. Data on patients were obtained from a prospectively compiled database, and the GRACE score was implemented to evaluate the probability of mortality. Patients were divided into three risk categories: low (&lt;10%), intermediate (10-19%), and high (≥20%), based on their predicted mortality percentages. Results: Patients in the high-risk group (Group 3) exhibited significantly lower Euro Scores and ejection fractions (EF) than those in the low and intermediate groups, as demonstrated by the study. Additionally, the cross-clamp time was notably longer in Group 3, highlighting the urgency of intervention in this population The postoperative complications' overall incidence did not differ significantly between the groups. Even though Group 3 exhibited an increased in-hospital mortality rate. Conclusions: The findings underscore the importance of timely intervention and tailored management strategies for NSTEMI patients, more specifically, the individuals who have been classified as high-risk by the GRACE score. This study contributes to the growing body of literature supporting urgent CABG as a lifesaving procedure and emphasizes the need for further research to optimize outcomes in this vulnerable patient population. The results advocate for a multidisciplinary approach to enhance perioperative care and improve survival rates among NSTEMI patients undergoing CABG.

Characteristics and In-Hospital Outcomes of Single-Vessel Coronary Disease Intervention: A Propensity-Matched Analysis of the National Inpatient Sample Database 2016–2020

Background/Objectives: Few studies have analyzed in-hospital complications and events following percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG) procedures for patients who underwent these interventions for single-vessel coronary artery disease (CAD). This study aims to compare the outcomes of PCI and CABG in such patients using a large propensity-matched real-world database based on procedural codes. Methods: Adult patients receiving PCI or CABG for single-vessel CAD were identified from the 2016–2020 National Inpatient Sample (NIS) database. Any cases targeting multi-vessel disease or employing a multi-treatment approach were excluded using appropriate procedural codes. Differences in events and complications from admission to discharge were studied between the two procedures (PCI vs. CABG) via logistic regression analysis. Results: After propensity matching with 273,380 patients in both groups, complication risks such as cardiac tamponade (aOR: 3.6 [3.27–3.96]), acute kidney injury (aOR: 1.53 [1.51–1.56]), cardiogenic shock (aOR: 1.38 [1.34–1.40]), procedural bleeding (aOR: 1.75 [1.67–1.83]), acute ischemic stroke (aOR: 1.89 [1.80–1.97]), and all-cause mortality (aOR: 1.05 [1.02–1.08]) were higher among CABG patients. No differences were observed for events of cardiac perforation (aOR: 0.92, [0.84–1.01]). Conclusions: In this large real-world propensity-matched analysis, CABG was associated with higher risks of multiple in-hospital complications and all-cause mortality compared to PCI following a single-vessel coronary intervention.

Abstract 4135984: Comparison of Immediate and Staged Complete Revascularization in STEMI Patients with Multivessel Disease: Meta-Analysis of Randomized Controlled Trial

Background: Patients diagnosed with ST-segment elevation myocardial infarction (STEMI) frequently present with multivessel coronary artery disease (CAD) at the time of primary percutaneous coronary intervention (PCI). The optimal timing of complete revascularization (CR) in these cases remains a subject of ongoing debate. Objective: To assess major cardiovascular outcomes and procedural complications in STEMI patients with multivessel CAD undergoing immediate versus staged CR post index procedure. Methods: We performed a systematic review and meta-analysis of randomized controlled trials (RCTs) comparing immediate to staged CR in STEMI and multivessel CAD. Trials were identified via a systematic search of MEDLINE, Embase, and Cochrane Libraries from database inception to March 6, 2024. The data were analyzed using RevMan software. Results: Among five RCTs (n=1,415) the majority of participants were male, the weighted mean follow-up duration across studies was 15.6 months. Immediate versus staged CR showed no significant differences in MACE (13.3% vs 9.8%; RR: 1.07, 95% CI [0.62, 1.83]), all-cause mortality (3% vs 4.55%; RR: 0.70, 95% CI [0.41, 1.21]), or MI (4.5% vs 2.6%; RR: 1.43, 95% CI [0.58, 3.55]). However, the staged group had higher unplanned revascularization incidence (8.6% vs 4.4%; RR: 1.92, 95% CI [1.21, 3.04]). Conclusion: Staged revascularization in STEMI patients with multivessel CAD demonstrates comparable effectiveness to immediate revascularization but leads to a greater number of unplanned revascularization procedures, likely due to delayed intervention. The early implementation of staged PCI during the initial hospitalization phase may provide equivalent efficacy to immediate complete revascularization. Nonetheless, further research is necessary to corroborate these findings.

Abstract 4123864: Fractional flow reserve-guided complete revascularization versus culprit-only revascularization in patients with myocardial infarction and multivessel disease: A GRADE assessed meta-analysis of randomized controlled trials

Background: Fractional flow reserve (FFR) guided complete revascularization (CR) is an approach that can be used to improve clinical outcomes in patients with acute myocardial infarction (MI) and multivessel disease (MVD). The objective of the present meta-analysis was to investigate whether FFR-guided CR leads to better cardiovascular outcomes as compared to culprit-only revascularization (COR) in acute MI and MVD by pooling recently published data. Methods: A comprehensive literature search was conducted using PubMed/MEDLINE, Embase, and the Cochrane Library from inception until April 2024 to retrieve eligible randomized controlled trials (RCTs). Clinical outcomes were assessed using the random-effects model by pooling risk ratios (RRs) along with 95% confidence intervals (CIs). We assessed the quality of evidence using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) methodology. Results: Four RCTs were pooled with 3,175 patients. FFR-guided CR significantly reduced the risk of repeat revascularization as compared to COR (RR = 0.52; 95% CI: 0.33-0.81, p = 0.004) [absolute risk difference 83 fewer per 1,000 patients (95% confidence interval: 116 to 33 fewer) moderate certainty]. Though there was a reduction in the risk of MACE with FFR-guided CR (RR = 0.68, 95% CI: 0.44-1.04, p = 0.08; moderate certainty), it didn't attain statistical significance. Clinical outcomes such as all-cause death (RR = 1.10, 95% CI: 0.84-1.45, p = 0.48; moderate certainty), cardiac death (RR = 0.79, 95% CI: 0.53-1.17, p = 0.24; high certainty), risk of MI (RR = 0.94, 95% CI: 0.54-1.66, p = 0.84; moderate certainty) and major bleeding (RR = 0.95, 95% CI: 0.54-1.67, p = 0.87; moderate certainty) were comparable between the two groups. Conclusion: FFR-guided CR in patients with MI and MVD can lead to a decreased risk of repeat revascularizations while not affecting all-cause and cardiac deaths.

Abstract 4132742: Fractional flow reserve guided complete revascularization versus Culprit-only percutaneous coronary intervention in patients with ST-segment elevation myocardial infarction and multivessel coronary artery disease. A meta-analysis of randomized controlled trials

Background: Data comparing the efficacy and safety of fractional flow reserve (FFR)-guided complete revascularization (CR) to culprit-only percutaneous coronary artery intervention (PCI) in patients with ST-segment elevation myocardial infarction (STEMI) and multivessel coronary artery disease are limited. Method: Pubmed, Embase and Cochrane were searched for randomized controlled trails (RCTs) comparing FFR-guided CR to Culprit-only PCI in patients with STEMI and multivessel CAD. A meta-analysis was performed on primary outcomes of major adverse cardiac events (MACE) and all-cause mortality. Heterogeneity was examined with I 2 statistics. A random-effects model was used for outcomes with high heterogeneity. Results: We included 4 RCTs with 3173 patients comparing FFR-guided CR with culprit-only PCI in patients with STEMI and multivessel coronary artery diseases. The pooled results of the 4 RCTs showed that MACE (RR=0.66; 95% CI [0.45, 0.99]; p=0.01; 16.8% vs 24.1%), PCI revascularization (RR=0.50; 95% CI [0.37, 0.67]; p&lt;0.00001; 13.1% vs 24.9%) and unplanned revascularization (RR=0.66; 95% CI [0.44, 0.99]; p=0.04; 8.7% vs 12.9%) were significantly reduced in the FFR-guided complete revascularization group compared to culprit-only PCI group. However, all-cause mortality (RR=1.09; 95% CI [0.84, 1.42]; p=0.53; 7.2% vs 6.0%), stroke (RR=1.02; 95% CI [0.38, 2.75]; p =0.97; 2.0% vs 1.8%), major bleeding (RR=0.95; 95% CI [0.54, 1.67]; p=0.87; 1.7% vs 1.7%), death from cardiovascular causes (RR=0.82; 95% CI [0.55, 1.21]; p=0.31; 3.1% vs 3.4%), MI (RR=1.09; 95% CI [0.60, 1.95]; p=0.78; 6.7% vs 6.4%), rehospitalization for HF (RR=0.72; 95% CI [0.44, 1.15]; p=0.17; 3.4% vs 5.3%), death from any cause or MI (RR=1.02; 95% CI [0.61, 1.71]; p=0.95; 14.9% vs 13.6%), any stent thrombosis (RR=1.42; 95% CI [0.35, 5.72]; p=0.62; 2.2% vs 1.4%), contrast induced nephropathy (RR=0.25; 95% CI [0.02, 2.79]; p=0.26), and CABG revascularization (RR=1.25; 95% CI [0.30, 5.15]; p=0.76) were not statistically different between groups. Conclusion: Our meta-analysis suggests that FFR-guided CR is safe and has superior efficacy to Culprit-only PCI in patients with ST-segment elevation myocardial infarction and multivessel coronary artery disease with significantly lowered incidence of MACE, PCI revascularization as well as unplanned or urgent revascularization. However, FFR-guided CR showed no beneficial effect on all-cause mortality, stroke, major bleeding and myocardial infarction.

Abstract 4119169: Navigating Complexity: The Carlino Technique in Multivessel Percutaneous Coronary Intervention for Chronic Total Occlusion

Introduction: Since the advent of percutaneous coronary intervention (PCI), the scope of this therapeutic intervention has broadened to include cases of life-threatening multivessel coronary artery disease that previously may have only been corrected surgically. PCI has become a common treatment of chronic total occlusion, and techniques continue to be developed to tackle more challenging cases. We present a complex case of NSTEMI with multi-vessel coronary artery disease treated with PCI via the Carlino technique. Case Description: A 60-year-old female with a history of hypertension, diabetes mellitus, and ischemic heart disease presented with severe chest pain that radiated to the neck and was associated with nausea and vomiting. Her EKG showed marked left-axis deviation, ST depressions in V2-V4, and RBBB. She was diagnosed with NSTEMI with a thrombolysis in myocardial infarction (TIMI) score of 5. She was loaded with aspirin and clopidogrel and was taken for left heart catheterization (LHC), which demonstrated three-vessel coronary artery disease with chronic 100% occlusion of the proximal left anterior descending artery, ostial 60-70% stenosis, and proximal 90-95% diseased left circumflex artery, while her right coronary artery had proximal 20-30% obstruction and mid 50-60% with right to left filling. The patient was advised CABG by the heart team, but the patient refused, and PCI was attempted on a shared decision basis. PCI was successful with the use of the Carlino technique: 0.5 ml of contrast dye was injected through a microcatheter to hydraulically recanalise the occlusion. The patient showed dramatic improvement and was discharged home on oral medications. Discussion: Treating multi-vessel coronary artery disease and CTO is challenging. PCI, particularly with the Carlino technique, offers a reliable approach. This technique, a modification of contrast-guided STAR, involves gentle contrast injection via microcatheter to modify plaque compliance and provide topographic information with regards to equipment location within vasculature, enhancing procedural success, especially in cases with impenetrable caps or calcified areas. Conclusion: This case is an example of how adaptive PCI techniques, such as the Carlino technique, can be employed to tackle complex instances of MvCAD that previously may have only been surgically corrected.

Abstract 4140139: Cardio-ankle vascular index (CAVI) in prediction of chronic coronary artery disease: risk, coronary artery lesions, and cardiovascular disease events

Introduction: The cardio-ankle vascular index (CAVI) is a significant metric for evaluating arterial function. The test measures the stiffness of the arteries from the beginning of the aorta to the ankle, and the algorithm used is not influenced by blood pressure. Recent statistics indicate that a high CAVI score has the potential to predict future cardiovascular disease (CVD) occurrences. However, no research has been conducted in Vietnam to investigate this matter. Methods: A prospective study was conducted on 222 patients. Out of these, 162 patients had chronic coronary artery disease (CAD), while the remaining 62 patients were free of CAD. The study took place between October 2019 and December 2022. Participants who fulfilled the criteria were evaluated using the CAVI baseline measurement and clinical and paraclinical parameters. A total of 162 patients with chronic coronary artery disease (CAD) were monitored for cardiovascular disease (CVD) events over a period of 2 years. Results: CAVI in chronic CAD patients (9.21±0.79) was significantly higher compared to those in free-CAD patients (8.48 ± 0.62) with p&lt;0.001. CAVI with a cut-off point ≥ 8.83 was a significant predictor for chronic CAD (OR = 9.6; 95%CI: 4.0-18.8). The Area under the curve (AUC) of CAVI for chronic CAD was 0.796 (95% CI: 0.736-0.856 ; p&lt;0.001). In addition, CAVI has a statistically significant increase in severe stenosis (≥75%) and multivessel coronary artery disease. CAVI in the CVD events group (9.77±1.06) was significantly higher than CAVI in the free–CVD events group (9.13±0.72) group (p=0.009). The patients with CAVI ≥9.63 have significantly higher CVD events (HR=6.4 ; 95% CI: 1.9-21.9, p=0.046). Conclusion: CAVI is higher in chronic CAD and can predict chronic CAD with a cut-off point ≥ 8.83. In chronic CAD, CAVI is higher in severe stenosis and multivessel coronary artery disease. Increased CAVI was significantly associated with CVD events.

Abstract 4137855: Hybrid Coronary Revascularization versus Traditional Coronary Artery Bypass Grafting for Left Main Disease

Background: The current guideline-recommended intervention for left main (LM) disease is coronary artery bypass grafting (CABG). Hybrid coronary revascularization (HCR) combines robotic coronary artery bypass and percutaneous coronary intervention (PCI) and offers a less invasive approach for patients with LM and multivessel coronary artery disease. We aim to compare clinical outcomes at 30 days, 6 months and 1 year between HCR and CABG in patients with LM disease. Methods: We retrospectively screened 761 patients who underwent bypass for LM disease between 2019 and 2023 at a single institution. A total of 118 patients who underwent either HCR (n=59) or CABG (n=59) were included after propensity matching for baseline characteristics. The primary endpoint was major adverse cardiovascular events (MACE), defined as death, myocardial infarction, repeat revascularization and stroke, at 30 days, 6 months and 1 year, which was assessed using chi-squared tests. Secondary outcomes are individual components of MACE at 30 days, 6 months and 1 year. Kaplan-Meier curves were used to visualize the difference in 1-year cumulative MACE-free survival across groups coupled with a log-rank test. Results: The mean age was 68.93±11 years for HCR patients and 68.41±10.11 years for CABG patients (p=0.394). SYNTAX score was high (&gt; 33) for 49.1% of HCR patients and 67.3% of CABG patients (p=0.15). Hospital length of stay was shorter for HCR compared to CABG (4.07 ± 1.21 days vs. 7.58 ± 7.71 days, p&lt;0.001). MACE events were significantly lower in the HCR group at 30 days (0% vs 10.2%; p=0.01), 6 months (0% vs 17%; p=0.002) and 1 year (2.4% vs 20.5%; p=0.01). The cumulative MACE-free survival at 1 year was significantly higher in the HCR group (p=0.007). There were no significant differences in secondary outcomes at any time point with the exception of lower repeat revascularization at 6 months in the HCR group (0% vs 10.9%; p=0.02). Conclusion: This retrospective study demonstrates that HCR is a viable alternative to CABG for LM disease. While randomized clinical trial data is still needed, this less invasive approach is a promising treatment strategy for patients with high surgical risk.

Abstract 4137058: Clinical Characteristics and Outcomes of South Asians Presenting with Acute Coronary Syndrome

Background: Patients of South Asian descent have a higher incidence of atherosclerotic cardiovascular disease and are affected by clinically significant coronary artery disease at an earlier age when compared to the general population. As a result, they have been shown to have a higher rate of cardiovascular events. This at-risk population has not been well studied as it pertains to acute coronary syndrome. Methods: Out of 1610 patients who presented to one of two tertiary care centers between 2021-2022 with a diagnosis of acute coronary syndrome and underwent coronary angiography, 240 patients were identified as being South Asian and were included in the study. 480 non-South Asian patients were randomly selected as controls. A retrospective analysis was conducted to study the demographics, risk factors, clinical presentation, diagnostic features, and outcomes of the two groups. Results: South Asian patients who were diagnosed with acute coronary syndrome and underwent coronary angiography were significantly younger than non-South Asian patients (61 vs 65 years, p &lt; 0.001). Though they were less likely to be smokers, they were significantly more likely to have other known risk factors including hypertension, dyslipidemia, and a history of prior myocardial infarction (p &lt; 0.001). South Asians had mean lower HDL (p = 0.02), higher triglycerides (0.006), and higher Hgb A1C (p &lt; 0.001). Surprisingly, rates of multivessel disease (defined as stenosis of 50% or greater in two or three vessels) were similar between the two groups. South Asians were more likely to be referred for CABG after initial coronary angiography most likely due to diffuse disease (p = 0.014). Clinical outcomes including pre-discharge LVEF, and 2-year mortality were similar between the groups. Conclusions: South Asians are a notoriously high-risk group when it comes to early-onset and more severe coronary artery disease. The pathophysiology behind this disproportionate manifestation of cardiovascular disease is not entirely understood, but several efforts to delineate this are ongoing. Our data demonstrate that this is at least in part, due to a higher prevalence of conventional modifiable and nonmodifiable risk factors in South Asian patients.

Complete versus culprit-only coronary revascularization in patients with myocardial infarction and multivessel disease undergoing percutaneous coronary intervention: an updated meta-analysis.

Recently, the FFR-Guidance for Complete Nonculprit Revascularization (FULL REVASC) trial in ST elevation myocardial infarction (STEMI) patients with multiple vessel disease (MVD) did not show differences in the composite endpoint of death from any cause, myocardial infarction, or unplanned revascularization than culprit-lesion-only percutaneous coronary intervention (PCI) at 4.8 years, although complete revascularization is a recommendation IA in current guidelines. We want to determine through an updated meta-analysis whether complete revascularization is associated with decreased mortality and hard clinical endpoints compared to culprit lesion only PCI. We searched MEDLINE, Embase, ISI Web of Science, and Cochrane Central Register of Controlled Trials) from January 1990 to April 2024 using the terms "percutaneous coronary intervention" combined with "non culprit lesions" or "culprit lesion" or "complete revascularization" or "incomplete revascularization." Additionally, a "snowball search" was conducted. Only randomized clinical trials (RCT) reporting mortality, re-infarction or new revascularization after at least 12 months and using predominantly drug eluting stents were included. The summary effect of different revascularization strategies on cardiovascular endpoints was estimated and measures of effect size were expressed as odds ratios (ORs). Eight RCT involving 9515 patients were included, with a follow-up range between 12 months and 4.8 years. Main findings show that culprit lesion revascularization was associated with an increased risk of MI (OR: 1.38; 95% CI: 1.05 to 1.81, I2 42%) and ischemia-guided revascularization (OR: 2.81; 95% CI: 1.86 to 4.26, I2 80%) compared to complete revascularization, without differences in overall mortality (OR: 1.15; 95% CI: 0.98 to 1.36, I2 2%). In patients with STEMI and MVD without cardiogenic shock, our metanalysis showed that complete revascularization with PCI significantly reduced the risk of non-fatal myocardial reinfarction and ischemic-driven revascularization compared to culprit vessel-only revascularization, without differences in overall mortality.

Recurrence of Cardiovascular Events After an Acute Myocardial Infarction in Patients with Multivessel Disease and Associated Healthcare Costs: A German Claims Data Analysis.

This study sought to quantify the healthcare costs of multivessel disease (MVD) and determine the prevalence and incidence of recurrent major adverse cardiovascular events (MACE) in high-risk patients diagnosed with MVD following an acute myocardial infarction (MI). This retrospective study utilized German claims data (AOK PLUS), between 01/01/2010 and 31/12/2020. Patients were included if they (1) had an inpatient diagnosis of an MI between 01/01/2012 and 31/12/2019 (index date), (2) were ≥ 18 years of age at date of MI diagnosis, and (3) had diabetes or met two of the following criteria: ≥ 65 years old, prior MI, peripheral arterial disease. MACE was defined as (1) MI, (2) stroke, or (3) death with a cardiovascular diagnosis within 30 days prior. To measure the burden of MVD, patients were identified during the index hospitalization by presence of MVD. Healthcare resource use and costs were compared after adjustment based on propensity score matching (PSM). A total of 5158 patients with evidence for MVD were included in the main analysis. 31.17% experienced a MACE within 365 days following the incident MI. After PSM adjustment, 33.22% of the MVD cohort experienced a MACE versus 36.48% of non-MVD patients. MVD patients had a higher rate of recurrent MI (14.22% vs. 9.81%). Additionally, public healthcare costs were about €4 million higher in the total MVD cohort than in the non-MVD cohort in the first year after an MI (€47,896,012.32 vs. €43,718,713.75, respectively), reflecting the MVD cohort's higher use of the public healthcare system. More MVD patients were prescribed guideline-recommended medication (61.4% vs. 46.0%). This study found that presence of MVD contributed to higher rates of recurrent MI. Patients with MVD experienced higher rates of recurrent MI despite a higher proportion of patients receiving guideline-directed medication therapy compared to non-MVD patients. Conversely, there was a higher mortality rate observed in the non-MVD cohort.

Predictive factors for multivessel disease in patients with acute coronary syndrome: analysis from the CCC-ACS project in China

BackgroundMultivessel disease(MVD) is linked to a poorer prognosis, increased complications, longer hospital stays, and higher in-hospital mortality when compared to single-vessel disease(SVD).The purpose of this study is to explore the clinically relevant predictors of acute cornary syndrome (ACS) combined with MVD.MethodsThis multicenter retrospective study included 68,378 ACS patients from 240 hospitals.The clinical data were retrospectively analyzed with univariate and multivariate analyses to identify the predictive factors for MVD.ResultsWhen compared to SVD group, the MVD group showed a higher incidence of Major Adverse Cardiovascular Events(MACCEs), including all-cause death, myocardial infarction, stent thrombosis, and ischemic stroke during hospitalization, These differences were found to be statistically significant (P < 0.05) .The multivariate analysis revealed that age over 75 years (OR: 1.246, 95% CI: 1.176, 1.319), LDL/HDL ratio > 1.98 (OR: 1.245, 95% CI: 1.192, 1.302), history of heart failure (OR: 1.446, 95% CI: 1.143, 1.829), hypertension (OR: 1.274, 95% CI: 1.225, 1.325), diabetes (OR: 1.341, 95% CI: 1.278, 1.406), eGFRs < 60 ml/min·1.73m2 (OR: 1.179, 95% CI: 1.112, 1.249), family history of CAD (OR: 1.236, 95% CI: 1.108, 1.379), and high homocysteine levels (OR: 1.209, 95% CI: 1.029, 1.420) are independent predictors of MVD. The incidence of multivessel disease increased from 37.7 to 58.6% with an increase in the number of predictive factors, while the incidence of single vessel disease decreased from 62.3 to 41.4%. This trend was statistically significant (P trend < 0.001).ConclusionsMVD is strongly correlated with a range of risk factors including diabetes, hypertension, LDL/HDL ratio greater than 1.98, hyperhomocysteinemia, family history of CAD, reduced glomerular filtration rate (< 60 ml/(min·1.73m2), age over 75 years, and a history of heart failure. Furthermore, as the number of predictive factors increases, the odds ratio (OR) for patients with MVD also increases, reaching 2.344 times the OR for patients without any predictive factors.

Gender-Dependent Association Between Thyroid Hormones and Severity of Coronary Artery Disease by SYNTAX Score

Thyroid function has been shown to be associated with cardiovascular diseases. Moreover, sex can influence on the association between thyroid function and other diseases. We aimed to evaluate the relationship between thyroid hormones and the severity of coronary artery disease (CAD) and outcomes. In a prospective study, patients with chest pain undergoing diagnostic coronary angiography were evaluated. Patients were categorized based on the number of involved coronary arteries. Moreover, the severity of CAD was quantitatively calculated using the Syntax score (SS). All patients were also followed up for 3-month duration. The level of TSH in 150 patients was significantly higher in females than males (3.1 [1.7, 5] versus 1.8 [1, 3.3] mU/L; P=0.002). There was significant correlation between THS and the SS among females (ρ=0.477, P&lt;0.001), but not males. Among both sexes, thyroid hormones were comparable between those with or without events during follow-up. The main predictors of high SS values included age (odds ratio [OR] 1.060, 95% confidence interval [CI] 1.018-1.104; P=0.005) and female (OR 2.941, 95% CI 1.198-7.218). The main predictors of multivessel disease were age (OR 1.077, 95% CI 1.026-1.132), female (OR 5.853, 95% CI 1.880-18.222), thyroxin (OR 0.733, 95% CI 0.547-0.981), and thyrotropin (OR 1.333, 95% CI 1.079-1.647). Thyroid hormones are associated with the presence and the severity of CAD, but it might be sex-related. However, thyroid hormone levels could not predict short-term outcomes of patients.

Invasive Treatment of Left Main Coronary Artery Disease: From Anatomical Features to Mechanistic Differences.

There is debate on the best treatment for significant stenoses of the left main (LM) coronary artery. The available evidence is based on four randomized trials, which were either performed specifically to assess patients with LM disease (EXCEL, NOBLE, PRECOMBAT) or had a significant fraction of patients with this disease pattern (SYNTAX). A meta-analysis revealed no difference in periprocedural and 5-year mortality but demonstrated a significant reduction of spontaneous myocardial infarction (MI) with CABG. Furthermore, the recently published SWEDEHEART registry data have shown survival advantage and fewer MACCE with CABG for LM disease after adjustment. In general, patients with more severe coronary artery disease (CAD) appear to have a survival advantage with CABG both over PCI and medical therapy (independent of the presence or absence of LM stenosis), which is always associated with a reduction of spontaneous MI in the CABG arm. Since the nomenclature of LM disease does not automatically reflect the complexity of CAD, we review the nature of LM disease in this article. We mechanistically assess the treatment effects of PCI and CABG for patients with LM disease, which is rarely isolated, often distal, and mostly associated with varying degrees of single and multi-vessel disease. We conclude that in patients with isolated LM shaft lesions and associated diseases of low complexity, the risk of spontaneous MI is lower, and PCI may achieve similar long-term outcomes compared to CABG. Thus, heart teams are essential for selecting the best treatment option and should focus on assessing infarction risk in chronic CAD.

Long-Term Impacts of Complete Revascularization on Clinical Outcomes in Patients with Coronary Chronic Total Occlusion

The impact of complete revascularization (CR), achieved through the recanalization of coronary chronic total occlusions (CTOs), on long-term patient outcomes remains uncertain.To evaluate this in patients who achieved CR after CTO-PCI with those who did not due to deferred CTO-PCI, the Asan Medical Center Registry was reviewed to identify coronary artery disease (CAD) patients with CTOs treated between January 2003 and December 2018. Patients were included with single-vessel disease with CTO and with multivessel disease who had undergone revascularization for non-CTO lesions. These subjects were divided into those who achieved CR with CTO-PCI and those who did not due to deferred CTO-PCI. Their outcomes were compared following 1:1 propensity score matching. Of the 2,746 enrolled CAD patients with CTOs, 1,837 achieved CR with CTO-PCI and 909 did not. Propensity score matching yielded 653 patient pairs. The CR-achieving group had a significantly lower 10-year risk of the primary composite outcome of death, myocardial infarction, stroke, or repeat revascularization (hazard ratio [HR]: 0.57; 95% confidence interval [CI]: 0.46–0.72; P < 0.001), as well as significantly lower risks of death (HR: 0.66; 95% CI: 0.51–0.87; P = 0.003) and repeat revascularization (HR: 0.67; 95% CI: 0.48–0.95; P = 0.023). CR was beneficial in all subgroups, including patients with major cardiovascular risk factors such as older age, hypertension, diabetes, and advanced CAD. Compared with incomplete revascularization, CR may significantly reduce the 10-year incidence of major adverse cardiac events in patients with CTO.

Understanding long-term risk in Percutaneous Coronary Intervention (PCI) in the Australian contemporary era with a focus on defining Complex Revascularisation in High-Risk Indicated Patients (CHIP)

BackgroundComplex Revascularisation in High-Risk Indicated Patients (CHIP) is emerging in Percutaneous Coronary Intervention (PCI). We document the frequency and outcomes following CHIP PCI in the Australian population, to understand risk and guide clinical decision-making. We propose a scoring system to define CHIP procedures. MethodsPatients undergoing PCI from Melbourne Intervention Group registry between 2005 and 2018 were analysed. Patients were stratified based on the number of high-risk features defined as 1)presence of ≥3 patient factors including age > 75yo, COPD, diabetes, renal impairment (eGFR<60 mL/min/1.73 m2), PVD, and 2)LVEF<30 %, and/or 3)having one complex coronary anatomical feature such as LMCA PCI, ACC/AHA B2/C lesion PCI, presence of multi-vessel disease or CTO PCI. National Death Index linkage was performed for long-term mortality analysis. Outcomes were analysed according to 4 risk categories – low risk(score 0), intermediate risk(score 1), high-risk(score 2), and very high-risk(score 3). Results20,973patients were analysed. Majority of patients underwent intermediate-risk procedures(71.7 %), with low rates of high-risk(6.6 %), and very high-risk(0.2 %). Lesion success inversely correlates with risk; low-risk(99.4 %), intermediate-risk(95.1 %), high-risk(94.3 %), very high-risk(92.5 %),p < 0.001. In-hospital and 30-day death correlates with risk; low-risk(0.0 %/0.1 %), intermediate-risk(0.3 %/0.5 %), high-risk(1.5 %/2.9 %), very high-risk(2.4 %/7.1 %),p < 0.001. Long-term mortality correlates with risk; low-risk(12.3 %), intermediate-risk(15.8 %), high-risk(49.3 %), very high-risk(76.2 %),p < 0.001. On multivariate analysis, increasing risk correlates with long-term mortality; intermediate-risk(HR1.41), high-risk(HR6.42), and very high-risk(14.05). ConclusionIn the Australian practice, proportion of patients undergoing high and very high-risk PCI procedures are low. Despite good procedural success and in-hospital outcomes, long-term mortality is poor. Further research into appropriate patient selection, and direct comparison of CHIP PCI to those treated medically and surgically should be considered.

Immediate Versus Staged Complete Revascularization for Patients With ST-Segment-Elevation Myocardial Infarction and Multivessel Disease: A Network Meta-Analysis of Randomized Trials.

The comparative outcomes with immediate, staged in-hospital, and staged out-of-hospital complete revascularization for patients with ST-segment-elevation myocardial infarction and multivessel disease remain unclear. An electronic search of MEDLINE, SCOPUS, and Cochrane databases was performed through August 2023 for randomized trials evaluating immediate, staged in-hospital, and staged out-of-hospital complete revascularization for patients with ST-segment-elevation myocardial infarction and multivessel disease. The primary outcome was major adverse cardiac events (MACEs). The final analysis included 9 trials with 4270 patients. The weighted follow-up duration was 13.8 months. On pairwise meta-analysis, there were no statistically significant differences between immediate versus staged nonculprit percutaneous coronary intervention (PCI) in MACEs (odds ratio, 0.79 [95% CI, 0.54-1.16]). Network meta-analysis showed that there was no statistically significant difference in MACEs with staged in-hospital nonculprit PCI (odds ratio, 1.29-[95% CI, 0.91-1.82]) compared with immediate nonculprit PCI, while there were higher odds of MACEs with out-of-hospital nonculprit PCI (odds ratio, 1.67-[95% CI, 1.21-2.30]) compared with immediate nonculprit PCI. Compared with immediate nonculprit PCI, there were higher odds of ischemia-driven repeat revascularization with staged out-of-hospital nonculprit PCI (odds ratio, 2.26-[95% CI, 1.37-3.72]), but not with in-hospital staged nonculprit PCI. There were no significant differences for the other outcomes among the 3 strategies. Among patients with ST-segment-elevation myocardial infarction with multivessel disease, an immediate nonculprit PCI approach was associated with similar clinical outcomes to the staged nonculprit PCI approach. The staged out-of-hospital nonculprit PCI approach was associated with a higher incidence of MACEs compared with the other strategies, which was driven by higher risk for ischemia-driven repeat revascularization.