Procedure For Coronary Artery Disease Research Articles

Abstract 17738: Cardiac MRI vs Coronary Angiography in Stable Coronary Artery Disease: A Head-to-Head Comparison

Introduction: Coronary angiography has been the gold standard invasive procedure for diagnosing and treating coronary artery disease (CAD). However, it poses risks and complications. In contrast, cardiac MRI offers non-invasive tools for early detection and diagnosis of CAD, presenting an alternative to angiography with fewer associated risks. Hypothesis: Our study aims to investigate if MRI can replace invasive procedures in stable CAD, reducing the need for such procedures while maintaining comparable diagnostic outcomes to coronary angiography. Methods: An extensive literature search was conducted, involving PubMed and Google Scholar databases up to February 2023. After careful evaluation, four clinical trials (CARMENTA, CE-MARC, MR INFORM, and MR Impact 2) comparing MRI and angiography in stable coronary artery disease were included in our study. Animal studies, expert opinions, literature reviews, and studies without reported MRI outcomes were excluded. Results: In the MR INFORM trial, among 221 patients with significant CMR-detected ischemia, 184 had confirmed angiographic lesions, while 35 did not. There were no significant differences in major adverse cardiovascular events or angina-free status at 1 year between the CMR and angiogram groups. The CE MARC 2 trial involving 752 patients reported a sensitivity of 86.5% and a specificity of 83.4% for multiparametric CMR, with a positive predictive value (PPV) of 77.2% and a negative predictive value (NPV) of 90.5%. The CARMENTA trial demonstrated a significant reduction in invasive coronary angiograms with CMR as the initial evaluation (87% vs. 100%), without significant differences in outcomes or the detection of obstructive coronary artery disease compared to computed tomography angiography. In the MR Impact 2 trial, CMR exhibited a sensitivity of 75% (±7%) and a specificity of 59% (±8%). The PPV, NPV, and accuracy for CMR were 70% (±5%), 65% (±5%), and 68% (±5%), respectively. Conclusions: CMR shows promise in diagnosing coronary artery disease, correlating well with angiography and reducing invasive procedures without significant outcome differences. Further research is needed to assess its clinical utility, highlighting its potential role in practice.

Home health care and cardiac rehabilitation following major cardiac surgeries in Pakistan.

Cardiovascular disorders are a leading cause of morbidity and mortality globally, and coronary artery bypass graft surgery is one of the most effective procedures for coronary artery disease. Cardiac rehabilitation (CR) has been shown to offer benefits beyond reducing mortality and morbidity rates, including enhancing patients' quality of life and reducing healthcare costs. Home-based CR programs offer personalized plans tailored to individual needs and availability and have been shown to be more effective in sustaining improvements than center-based CR programs. However, there are challenges associated with providing home care services in developing countries, including personnel shortages, lack of financing and policies, and limited access to end-of-life or hospice services. The use of multidisciplinary telehealth and telecare homecare programs that make use of web-based technologies to monitor postoperative outcomes in patients undergoing cardiac surgery may provide a solution to some of these challenges. This manuscript emphasizes the potential of home health care and CR in improving postoperative outcomes in Pakistan and identifies some of the challenges and potential solutions associated with providing home care services.

Diagnostic accuracy for coronary artery disease by computed tomography angiography as compared to conventional invasive angiography

Background: Emerging as a major cause of death and disability in the developing countries is coronary artery disease (CAD). Traditional coronary angiography has traditionally been the preferred diagnostic procedure for CAD. Non-invasive evaluation of coronary artery disease (CAD) using computed tomography (CT) coronary angiography shows promise. This observational study's goal is to assess the relative efficacy of noninvasive multi-section computed tomography (MSCT) coronary angiography vs invasive selective coronary angiography in detecting coronary stenosis.Method and patient: This observational study carried out in the Azadi teaching Hospital/Kirkuk between November 2021 to March 2022. Patients who suspected to have coronary artery disease underwent both CTCA and invasive coronary angiography in different centers in our country comparing and analyzing their results.Result: In total, 92 participants were enrolled in the trial. Patients had a mean age of 57.207.3 years, and men made up the vast majority of those who appeared (67.3 percent). Chest pain was the most common presenting complaint (94 percent). Patients exhibited a prevalence of 84% for HTN, 55% for hyperlipidaemia, 58% for diabetes, and 4% for ischemic heart disease. In addition, 50% of the patients are either current or former smokers. Half of the patients received 64-slice CT scans, nearly half had 128-slice scans, and 3.2% got 256-slice scans. CCTA's sensitivity was 100%, and its specificity was 66.7%. Positive predictive value for CCTA was 98.8 percent (meaning it correctly identified positive cases in 98.8 percent of patients) and negative predictive value was 100 percent, for a total diagnostic accuracy of 98.9 percent (which mean CCTA can exclude all negative cases and did not miss any case). When looking at individual arteries, the LAD artery was shown to be the most accurate, while the LCX artery was the least accurate (95.6 percent and 78.2 percent respectively). In terms of sensitivity, LAD performed at a 99.1% rate, while LMS performed at a 0% rate (33.3 percent). RCA had the most specificity (95.2 percent), whereas LAD had the lowest (88.8 percent) (40 percent). In order to determine what factors, influence CCTA positivity, we performed a binary logistic regression analysis for positive CCTA (negative as reference) with all variables from the studies. The results showed that IHD, lesions in the LAD artery, lesions in the LCX artery, and CT slice thickness (128 and 256 slices) all have a negative effect on CCTA (p0.05).Conclusions: When compared to traditional angiography, multi-slice computed tomography has demonstrated superior sensitivity and specificity for the identification of coronary artery disease.

The manifestation of anxiety in patients undergoing elective coronary angiography

IntroductionPrevalence of anxiety disorders in coronary artery disease reaches up to 15% and about half of patients with coronary artery disease have anxiety or depression comorbidity. Prevalence of anxiety in patients undergoing percutaneous coronary intervention ranges from 24% to 72%. Anxiety can be the source of distress and is associated with poor prognosis, impaired health-related quality of life and can cause cardiac dysfunction.ObjectivesWe aimed to determine the prevalence of anxiety and its association to coping strategies and personality traits in non-depressed patients undergoing elective coronary angiography, a diagnostic procedure for coronary artery disease. We also aimed to determine the correlation of state anxiety to elective coronary angiography finding and its expression over time.MethodsThis was a single-center, cross-sectional, prospective study. Anxiety was evaluated at four-time points using self-rating questionnaires: 14 days prior to and 2–4h before procedure; 24h after procedure and 6 weeks after discharge. The association between anxiety and psychological variables was assessed by multiple linear regression and by linear mixed effect model.ResultsA total of 259 non-depressed patients were included in the final analysis (median age 65, 32% were female). Prevalence of anxiety was 35% and was higher in patients with avoidance-oriented coping style (p<0.001), meanwhile low neuroticism (p<0.001) and extrovertive personality trait (p=0.032) were protective factors. Patients that had no intervention (p=0.022) or had percutaneous coronary intervention (p=0.010) during elective coronary angiography, had lower anxiety than patients in need for coronary artery bypass graft surgery.ConclusionsPersonality traits emotional stability and extroversion are protective factors against anxiety. More than one third of patients experienced clinically significant anxiety before procedure. Our results suggest that recognising anxiety in patients undergoing elective coronary angiography is important. Further on, application of effective interventions for reducing/treating anxiety before or after procedure is needed.Disclosure of InterestNone Declared

A Quasi Experimental Study to Evaluate the Effectiveness of Audio-Visual Education on Anxiety among patients undergoing Coronary Angiography at selected hospital, Coimbatore

Coronary angiography is the most widely used interventional and diagnostic procedure for coronary artery disease. The patient experiences the pre-procedural anxiety prior to coronary angiography. The main aim of the study was to identify the effectiveness of audio-visual education on anxiety among patients undergoing coronary angiography. Quasi experimental posttest only control group design was adopted in the study. By using Non probability purposive sampling technique 60 participants were selected and 30 were assigned to the experimental and control group respectively. The demographic variables, clinical variables were collected from the patients undergoing coronary angiography. Audio- Visual Education was provided to the patients in the experimental group for 15 minutes. Routine nursing care was provided to patients in the control group. After audio-visual education, Post-test was conducted by using the State anxiety inventory scale for both experimental and control group. It was identified that the calculated mean level of anxiety in the experimental and control group was 34.3 and 61.2 respectively with the mean difference of 26.9. Likewise the standard deviation of the experimental and control group was 10.9 and 7.9 respectively. The calculated ‘t’ value 10.79 was greater than the table value of 1.96 at 0.001 level of significance. Hence, it was concluded that Audio-visual education is an effective method in reducing the anxiety among patients undergoing coronary angiography.

Coronary endarterectomy in patients with diffuse coronary artery disease: assessment of graft patency with computed tomography angiography.

Background:With a growing population of patients with advanced coronary artery disease (CAD), many of whom have undergone prior percutaneous coronary interventions, coronary endarterectomy (CE) allows for the extension of revascularization in patients with otherwise limited options. Whether adjunctive CE associated with standard surgery, combined with contemporary antiplatelet therapy, improves outcomes remains largely unknown.Methods:We studied 147 consecutive patients who underwent 154 adjunctive CE procedures for advanced CAD between January 2015 and January 2018. We used computed tomography angiography (CTA) in a subgroup of 32 consecutive patients who underwent CE during coronary artery bypass grafting after June 2016 to assess graft and coronary patency.Results:Patients (mean age 67 ± SD 10 yr) underwent CE of the right (102 patients), the left anterior descending (LAD, 22 patients) and the circumflex (17 patients) coronary arteries. Seven patients (5%) experienced a procedural myocardial infarction and there were no perioperative deaths. Among the 32 patients who underwent CTA 3 months after surgery, the mean patency of the endarterectomized coronary arteries and bypass grafts was 90% and 88%, respectively. All 6 arterial grafts on the LAD artery were patent. The mean survival rate and the mean rate of freedom from major adverse cardiovascular events was 95% ± 2% and 95% ± 6%, respectively. The patency rate was 100 % for patients evaluated at 3-year follow up.Conclusion:Coronary endarterectomy offers a surgical option for patients with diffuse CAD who may be unsuitable for coronary bypass alone. Grafts and endarterectomized coronary artery patency remain adequate and explain the excellent patient survival and the freedom rate from major adverse cardiovascular events.

Role of Late Gadolinium Enhancement in the Assessment of Myocardial Viability.

Background: Prior to any revascularization procedure for coronary artery disease, it is essential to identify viable myocardium which will likely benefit from it. In such a situation, delayed enhanced cardiac MRI is beneficial.Methods: Our study consisted of 50 patients with at least a one-month prior history of myocardial infarction (MI), abnormal findings on electrocardiography (ECG), and 2D-echocardiography (2D-ECHO), who were subjected to cardiac MRI performed on a 3T MRI machine. The MRI scans were evaluated for anatomical and especially functional characteristics of the heart, such as wall motion. On late gadolinium enhancement (LGE), the diseased segments were classified into two categories: < 50% LGE (viable) and > 50% LGE (non-viable).Results: Of the 378 diseased segments detected on LGE, 137 (36.2%) segments showed < 50% LGE and 241 (63.8%) segments showed > 50% LGE. The segments showing < 50% LGE showed normokinesia or hypokinesia, with none of the segments showing akinesia or dyskinesia, whereas the segments showing > 50% LGE showed akinesia or dyskinesia predominantly. This was found to be statistically highly significant (p-value < 0.001). Conclusion: Delayed enhanced-cardiac magnetic resonance (DE-CMR) imaging in patients with ischemic heart disease (IHD) helps evaluate the severity of the infarcted myocardium by classifying the diseased myocardium into viable and non-viable, as viable myocardium is more likely to regain functional recovery than non-viable myocardium. It also predicts the functional recovery of the myocardium after revascularization therapy.

Comparison of clinical outcomes between percutaneous coronary intervention for the de novo lesion versus in-stent restenosis lesion

Abstract Background and objective Percutaneous coronary intervention (PCI) with metallic coronary stent (bare-metal stents [BMS] and drug-eluting stents [DES]) implantation is most frequently performed therapeutic procedures for coronary artery disease. In-stent restenosis (ISR) is a critical drawback of metallic coronary stents. Incidence of ISR has been reported in up to 30% after BMS implantation. The use of DES has greatly reduced the proportion of restenosis compared with the BMS. However, ISR still remains the primary concern after PCI even in the contemporary DES era, and thought to be associated with worse clinical outcomes. However, comparative data on ISR and de novo lesions are rare. Purpose The aim of the present study was to compare the clinical outcomes after PCI for the de novo lesion and the ISR lesion. Methods We performed a retrospective analysis of patients who underwent PCI between 2013 and 2020. The incidences of major adverse cardiac and cerebrovascular events (MACCE) and all-cause death were evaluated. MACCE was defined as composite of cardiovascular death, non-fatal myocardial infarction, and stroke. Results In this study, 1538 patients were enrolled and divided into two groups: PCI for de novo lesion group (n=1258, 81.8%), and PCI for ISR lesion group (n=280, 18.2%). Patients in the ISR lesion group were significantly older and had higher prevalence of hypertension, diabetes mellitus, dyslipidemia and chronic kidney disease than patients in the de novo lesion group. During a median follow-up period of 1.9 years, Kaplan-Meier curves showed no significant differences in the incidences of MACCE (log-rank, p=0.86) and all-cause death (p=0.84) between two groups. After adjustment for other covariates, PCI for ISR lesion were not significantly associated with MACCE (hazard ratio [HR], 1.10; 95% confidential interval [CI], 0.61–1.97; p=0.76) and all-cause death (HR, 0.93; 95% CI, 0.56–1.56; p=0.79) Conclusion PCI for the ISR lesion was not associated with worse clinical outcomes compared with PCI for the de novo lesion. Funding Acknowledgement Type of funding sources: None.

Profiles of Hospitalized Patients with Angiographic Coronary Heart Disease in Taiwan during 2014-2016: Report of a Tertiary Hospital.

The Taiwan Society of Cardiology (TSOC) has established multicenter registries for coronary artery disease (CAD) to investigate clinical characteristics, management and risks for mortality. However, the impacts of newly-emerged evidence-based therapies, including the use of drug-eluting stents (DESs), on patients with CAD in Taiwan remain unclear. The Tri-Service General Hospital-Coronary Heart Disease (TSGH-CHD) registry is a single-center, prospective, longitudinal registry in Taiwan containing data from 2014-2016. Individuals who were admitted for coronary angiography were enrolled. Patient profiles, management and in-hospital outcome data were collected. We included 3352 patients: 2349 with stable angina and 1003 with acute coronary syndrome (ACS). In the stable angina group, both patients receiving stenting and those receiving medical treatment had a 0.7% mortality rate; DESs were used in 70.4% of the patients receiving stenting. In the ACS group, the patients receiving stenting and those receiving medical treatment had a 4.9% and 10.7% mortality rate, respectively; DESs were used in 63.1% of the patients receiving stenting. In the 2008-2010 Taiwan ACS registry, DESs were used in only 28% of all stenting procedures, and the estimated hospital mortality rate was 1.8%. Multivariate analysis indicated that older age, prior stroke, and cardiogenic shock on admission were associated with an increased risk of in-hospital mortality in the ACS group. Compared with the Taiwan ACS cohort, the TSGH-CHD registry revealed increased DES use and increased disease complexity and severity after 2010. Although unlikely to significantly improve survival, interventionists seemed to perform high-risk procedures for complex CAD more often in the new DES era.

Obesity and Cardiovascular Disease: A Scientific Statement From the American Heart Association.

The global obesity epidemic is well established, with increases in obesity prevalence for most countries since the 1980s. Obesity contributes directly to incident cardiovascular risk factors, including dyslipidemia, type 2 diabetes, hypertension, and sleep disorders. Obesity also leads to the development of cardiovascular disease and cardiovascular disease mortality independently of other cardiovascular risk factors. More recent data highlight abdominal obesity, as determined by waist circumference, as a cardiovascular disease risk marker that is independent of body mass index. There have also been significant advances in imaging modalities for characterizing body composition, including visceral adiposity. Studies that quantify fat depots, including ectopic fat, support excess visceral adiposity as an independent indicator of poor cardiovascular outcomes. Lifestyle modification and subsequent weight loss improve both metabolic syndrome and associated systemic inflammation and endothelial dysfunction. However, clinical trials of medical weight loss have not demonstrated a reduction in coronary artery disease rates. In contrast, prospective studies comparing patients undergoing bariatric surgery with nonsurgical patients with obesity have shown reduced coronary artery disease risk with surgery. In this statement, we summarize the impact of obesity on the diagnosis, clinical management, and outcomes of atherosclerotic cardiovascular disease, heart failure, and arrhythmias, especially sudden cardiac death and atrial fibrillation. In particular, we examine the influence of obesity on noninvasive and invasive diagnostic procedures for coronary artery disease. Moreover, we review the impact of obesity on cardiac function and outcomes related to heart failure with reduced and preserved ejection fraction. Finally, we describe the effects of lifestyle and surgical weight loss interventions on outcomes related to coronary artery disease, heart failure, and atrial fibrillation.

Determination of the Entire Stent Surface Area by a New Analytical Method

Stenting is a widely used treatment procedure for coronary artery disease around the world. Stents have a complex geometry, which makes the characterization of their corrosion difficult due to the absence of a mathematical model to calculate the entire stent surface area (ESSA). Therefore, corrosion experiments with stents are mostly based on qualitative analysis. Additionally, the quantitative analysis of corrosion is conducted with simpler samples made of stent material instead of stents, in most cases. At present, several methods are available to calculate the stent outer surface area (SOSA), whereas no model exists for the calculation of the ESSA. This paper presents a novel mathematical model for the calculation of the ESSA using the SOSA as one of the main parameters. The ESSA of seven magnesium alloy stents (MeKo Laser Material Processing GmbH, Sarstedt, Germany) were calculated using the developed model. The calculated SOSA and ESSA for all stents are 33.34%(±0.26%) and 111.86 mm (±0.85 mm), respectively. The model is validated by micro-computed tomography (micro-CT), with a difference of 12.34% (±0.46%). The value of corrosion rates calculated using the ESSA computed with the developed model will be 12.34% (±0.46%) less than that of using ESSA obtained by micro-CT.

Particularities of cardiovascular rehabilitation after coronary artery bypass graft: a case report

Objectives. This paper assesses the importance and contribution of cardiovascular rehabilitation programs in the short- and long-term outcome following surgical revascularization procedures for patients with coronary artery disease (CAD). Methods. We present the case of a 64-year-old patient who benefited from a coronary artery bypass graft (CABG) procedure for CAD, followed by an individualized cardiac rehabilitation program. The case particularity consisted of the presence of associated peripheral vascular disease that imposed additional challenge in decision-making process regarding surgical therapy. Results and discussion. Immediately after surgery, the patient was included in a phase II residential recovery program, preceded by a ramp effort test. The rehabilitation program consisted of partial toning massage of the lumbosacral spine, and individual physiotherapy. Coronary revascularization procedures often cause lowered exercise capacity and declining physical activity levels. In our case even preoperative assessment showed a limited physical effort capacity, further reduced by the surgical intervention. The physiotherapy plan should be personalized, safe, effective, and must increase the independent mobility of patient soon after open heart surgery. Conclusions. The main contribution of cardiac rehabilitation program should be the improvement of physical and social status of patients undergoing surgical myocardial revascularization. This program should be included in the management of all cardiac heart disease patients who benefit from cardiac surgery procedures. Implementation of CR programs at most hospitals and community centres, as well as awareness about their efficacy, would result in higher participation after coronary revascularization interventions and improvement of functional parameters and quality of life.

Revascularization for Coronary Artery Disease: Principle and Challenges.

Coronary revascularization is the most important strategy for coronary artery disease. This review summarizes the current most prevalent approaches for coronary revascularization and discusses the evidence on the mechanisms, indications, techniques, and outcomes of these approaches. Targeting coronary thrombus, fibrinolysis is indicated for patients with diagnosed myocardial infarction and without high risk of severe hemorrhage. The development of fibrinolytic agents has improved the outcomes of ST-elevation myocardial infarction. Percutaneous coronary intervention has become the most frequently performed procedure for coronary artery disease. The evolution of stents plays an important role in the result of the procedure. Coronary artery bypass grafting is the most effective revascularization approach for stenotic coronary arteries. The choice of conduits and surgical techniques are important determinants of patient outcomes. Multidisciplinary decision-making should analyze current evidence, considering the clinical condition of patients, and determine the safety and necessity for coronary revascularization with either PCI or CABG. For coronary artery disease with more complex lesions like left main disease and multivessel disease, CABG results in more complete revascularization than PCI. Furthermore, comorbidities, such as heart failure and diabetes, are always correlated with adverse clinical events, and a routine invasive strategy should be recommended. For patients under revascularization, secondary prevention therapies are also of important value for the prevention of subsequent adverse events.

Incident arterial vascular events in a cohort of Puerto Ricans with rheumatoid arthritis.

Objective:The increased morbidity and mortality associated with cardiovascular events in patients with rheumatoid arthritis has been linked to traditional and nontraditional factors. However, these factors vary among different ethnicities. Few studies have described these features in Hispanic populations. Thus, we determined the clinical correlates of arterial vascular events in Hispanics from Puerto Rico.Methods:A cross-sectional study was performed in a cohort of 405 Puerto Ricans with rheumatoid arthritis. Demographic parameters, health-related behaviors, clinical manifestations, disease activity (per Disease Activity Score 28), functional status (per Health Assessment Questionnaire), comorbidities, and pharmacotherapy were compared in patients with and without incident arterial vascular events. The latter was defined as the occurrence of myocardial infarction, angina pectoris, vascular procedures for coronary artery disease, stroke, or peripheral artery disease. Study groups were analyzed using bivariate and multivariate analyses.Results:Of the total study population, 87.2% were woman. The mean age at study visit was 56.1 ± 13.9 years, and the mean disease duration was 15.0 ± 13.2 years. Arterial vascular events occurred in 43 patients (10.6%). In the multivariate analysis adjusted for age and sex, arterial hypertension, dyslipidemia, metabolic syndrome, extra-articular manifestations, higher Health Assessment Questionnaire score, and number of hospitalizations were associated with arterial cardiovascular events.Conclusion:In this cohort of Puerto Ricans with rheumatoid arthritis, traditional and nontraditional factors, particularly extra-articular manifestations and functional disability, were associated with arterial vascular events. Awareness of these associations may help to implement clinical strategies in this group of rheumatoid arthritis patients at risk of arterial vascular events.

Study of risk factors associated with adverse outcome in a severe coronary artery disease (syntax score &gt;22) with different therapeutic strategies

Background: The specific question of whether PCI or surgical treatment offers any advantage over MT in patients with stable angina and multivessel disease remains unanswered. Objective of our research was to study various risk factors which interferes the outcome of various therapeutic procedures in coronary artery disease.Methods: This was prospective observational study carried out in a tertiary care center from July 2014 to July 2016. A total of 98 subjects undergoing different therapeutic strategies were followed up. Risk factors which interferes the outcome of various therapeutic procedures in coronary artery disease (CAD) were studied.Results: There was a significant difference in mean SYNTAX score (P = 0.003), urine micro albumin levels (P=0.006), and body mass index (0.046) between those who had MACE and who did not have MACE.Conclusions: The urine micro albumin &gt;30 mg/l and highest SYNTAX score were significantly associated with MACE at 1 year in subject with severe CAD.

Resetting the Bar to Reduce Radiation Exposure During Ablation of Cardiac Arrhythmias

See Article by Pani et al Electrophysiology procedures are dependent on imaging technologies to position pacemaker or implantable cardioverter defibrillator leads, perform extractions, or position catheters for diagnostic studies or ablation procedures. In most cases, these procedures depend on radiological imaging, which exposes patients and medical personnel to the potential risks of radiation exposure. This has been the subject of 2 consensus documents developed by the American College of Radiology to improve safe practice during interventional procedures for coronary artery disease, valve disease, or electrophysiological studies.1,2 The emphasis of these documents has been on best practice to achieve the lowest reasonably achievable dose. These goals depend on up-to-date imaging systems, collimation of the beam, minimizing steep angulation, optimizing distance between patient and the x-ray tube and the image intensifier, and avoiding any exposure that is not necessary. There are guidelines for hospitals to ensure that their physicians have received basic training for radiation safety and know how to operate their equipment to achieve these goals.3 Because our procedures have become more complex, the need for detailed imaging has become more important. This has increased the potential risks of radiation exposure to patients and the lifetime exposure for medical personnel, which is greatest for the physicians who perform the procedure. In response to these concerns, industry has devoted substantial effort into development of electroanatomic 3-dimensional imaging systems that do not depend on radiation and new radiographic technologies that reduce our exposure to radiation. Reductions in frame rate and other measures compromise the image quality to some extent, but these parameters can be adjusted during the case to enhance the image …

New predictors of in-stent restenosis in patients with diabetes mellitus undergoing percutaneous coronary intervention with drug-eluting stent.

BackgroundPercutaneous coronary intervention (PCI) had become the major therapeutic procedure for coronary artery disease (CAD), but the high rate of in-stent restenosis (ISR) still remained an unsolved clinical problem in clinical practice. Increasing evidences suggested that diabetes mellitus (DM) was a major risk factor for ISR, but the risk predictors of ISR in CAD patients with DM had not been well characterized. The aim of this study was to investigate the clinical and angiographic characteristic predictors significantly associated with the occurrence of ISR in diabetic patients following coronary stenting with drug-eluting stent (DES).MethodsA total of 920 patients with diabetes who diagnosed CAD and underwent coronary DES implantation at Beijing Anzhen Hospital in China were consecutively enrolled from January 2012 to December 2012. Of these, 440 patients underwent the second angiography within ≥ 6 months due to the progression of treated target lesions. Finally, 368 of these patients who met the inclusion and exclusion criteria were followed up by angiography after baseline PCI. According to whether ISR was detected at follow-up angiography, patients were divided into the ISR group (n = 74) and the non-ISR group (n = 294). The independent predictors of ISR in patients with DM were explored by multivariate Cox's proportional hazards regression models.ResultsA total of 368 patients (260 women and 108 men) with a mean ages of 58.71 ± 10.25 years were finally enrolled in this study. Of these, ISR occurred in 74/368 diabetic patients (20.11%) by follow-up angiography. Univariate analysis showed that most baseline characteristics of the ISR and non-ISR group were similar. Patients in the ISR group had significantly higher serum very low density lipoprotein cholesterol (VLDL-C), triglyceride (TG) and uric acid (UA) levels, more numbers of target vessel lesions, higher prevalence of multi-vessel disease, higher SYNTAX score, higher rate of previous but lower rate of drinking compared with patients in the non-ISR group. The independent predictors of ISR in patients with DM after DES implantation included VLDL-C (HR = 1.85, 95% CI: 1.24–2.77, P = 0.002), UA (per 50 µmol/L increments, HR = 1.19, 95% CI: 1.05–1.34, P = 0.006), SYNTAX score (per 5 increments, HR = 1.34, 95% CI: 1.03–1.74, P = 0.031) and the history of PCI (HR = 3.43, 95% CI: 1.57–7.80, P = 0.003) by the multivariate Cox's proportional hazards regression analysis.ConclusionsThe increased serum VLDL-C and UA level, higher SYNTAX score and the history of previous PCI were independent predictors of ISR in patients with DM after coronary DES implantation. It provided new evidence for physicians to take measures to lower the risk of ISR for the better management of diabetic patients after PCI.

Effectiveness of Tongguan capsules on restenosis after coronary stent implantation: a randomised controlled trial

BackgroundAlthough percutaneous coronary intervention (PCI) has become a widely used therapeutic procedure for coronary artery disease, stent restenosis limits the benefits of this revascularisation. The question of how to prevent such events remains unresolved. Empirical evidence suggests that Tongguan capsules, a patented Chinese Medicine, can decrease frequency and duration of angina pectoris attacks; however, evidence supporting its efficacy on restenosis remains inadequate. We aimed to determine whether Tongguan capsules could reduce restenosis incidence in patients after successful stent implantation. MethodsIn this single-centre, open-label randomised controlled trial, patients undergoing percutaneous coronary stent deployment who were aged 18–80 years were enrolled from Guangdong Provincial Hospital of Chinese Medicine and randomly assigned (1:1) to receive either Tongguan capsules for 3 months (4·5 g/day; Tongguan group) or nothing (control group). All patients received standard anti-platelet, anti-coagulation, and lipid-decreasing treatments, concurrently. The Clinical Research Centre from Guangzhou University of Chinese Medicine generated separate randomisation schedules using a random number generator. All attending physicians, investigators, and the biostatisticians performing the analysis were masked to treatment assignment. The primary clinical endpoint was the 12-month incidence of any major adverse cardiovascular event (defined as cardiac death, myocardial infarction, or recurrence of symptoms requiring additional revascularisation). The primary angiographic endpoint was restenosis incidence at 6 months. The Clinical Research Ethical Committee at Guangdong Provincial Hospital of Chinese Medicine approved the research protocol (Z2017008-01). This trial was registered in ChiCTR (ChiCTR-IIR-17011407). All participants provided written informed consent before enrolment. FindingsWe enrolled 326 patients between Aug 1, 2014, and Dec 1, 2015. Of these patients, 163 were randomly assigned to the Tongguan group and 163 to the control group. Four patients were excluded leaving 322 patients (160 in the Tongguan group and 162 in the control group) for analysis. Compared with the control group, 12-month incidence of major adverse cardiovascular events was reduced in patients treated with Tongguan capsules (12·5% [20 of 160] vs 23·5% [38 of 162], p<0·0001); 6-month restenosis incidence did not differ between groups (3·1% [five of 160] in the Tongguan group vs 4·3% [seven of 162] in the control group, p=0·779). InterpretationAlthough not significant, there was a trend towards a reduction in restenosis and therefore more research is needed to establish whether Tongguan capsules can improve clinical outcomes. Further higher quality and more rigorous randomised trials with larger sample size are needed to attain more robust clinical evidences of Tongguan capsules. FundingNational Science Foundation (81473471, 81202782, 81573708).

Thrombotic thrombocytopenic purpura presenting as acute coronary syndrome

Key Clinical MessageIn patients presenting with thrombotic thrombocytopenia purpura and non‐ST elevation myocardial infarction, prompt initiation of plasma exchange takes precedence over other invasive diagnostic procedures for coronary artery disease. Such procedures should be delayed until clinical condition and laboratory parameters have been stabilized.

An Australian longitudinal pilot study examining health determinants of cardiac outcomes 12months post percutaneous coronary intervention.

BackgroundPercutaneous coronary intervention (PCI) is a very common revascularisation procedure for coronary artery disease (CAD). The purpose of this study was to evaluate cardiac outcomes, health related quality of life (HRQoL), resilience and adherence behaviours in patients who have undergone a PCI at two time points (6 and 12 months) following their procedure.MethodsA longitudinal pilot study was conducted to observe the cardiac outcomes across a cohort of patients who had undergone a percutaneous coronary intervention (PCI). Participants who had undergone PCI 6 months prior were invited. Those participants who met the inclusion criteria and provided consent then completed a telephone survey (time point 1). These participants were then contacted 6 months later (i.e. 12 months post-intervention, time point 2) and the measures were repeated.ResultsAll patients (n = 51) were recorded as being alive at time point 1. The multiple model indicated that controlling for other factors, gender was significantly associated with a linear combination of outcome measures (p = 0.004). The effect was moderate in magnitude (partial-η2 = 0.303), where males performed significantly better than females 6 months after the PCI procedure physically and with mood. Follow-up univariate ANOVAs indicated that gender differences were grounded in the scale measuring depression (PHQ9) (p = 0.005) and the physical component score of the short form measuring HRQoL (SF12-PCS) (p = 0.003). Thirteen patients were lost to follow-up between time points 1 and 2. One patient was confirmed to have passed away. The pattern of correlations between outcome measures at time point 2 revealed statistically significant negative correlation between the PHQ instrument and the resilience scale (CD-RISC) (r = -0.611; p < 0.001); and the physical component score of the SF-12 instrument (r = -0.437; p = 0.054).ConclusionsMen were performing better than women in the 6 months post-PCI, particularly in the areas of mood (depression) and physical health. This pilot results indicate gender-sensitive practices are recommended particularly up to 6 months post-PCI. Any gender differences observed at 6 month appear to disappear at 12 months post-PCI. Further research into the management of mood particularly for women post-PCI is warranted. A more detailed inquiry related to access/attendance to secondary prevention is also warranted.