Revascularization For Coronary Artery Disease Research Articles

Routine Angiographic Follow-Up After Coronary Artery Disease Revascularization: Is Seeing Believing?

Coronary artery disease is a major cause of mortality and morbidity in the world, and PCI and CABG account for over a million procedures performed annually in the USA. The goal of percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG) is to achieve complete revascularization (CR) if at all possible. However, restenosis and stent thrombosis (ST) remain the Achilles heel of contemporary PCI with restenosis rates between 10 and 30% with bare metal stents to 5-15% after drug-eluting stents and ST rates of around 0.8 vs 1.2%, respectively. Routine angiography after revascularization seems theoretically attractive as this may allow intervention before clinical events occur. In this manuscript, we review the literature regarding routine angiography after PCI or CABG and its outcomes. According to the 2016 update from the American Heart Association (AHA), 15.5 million people above the age of 20 have coronary heart disease (CHD) in the USA. The prevalence of CHD is now almost similar in both men and women, and one American suffers from a myocardial infarction (MI) every 42s. Recent data from randomized clinical trials and observational studies does not support the use of routine coronary angiography after revascularization in asymptomatic patients. There are some studies which show that routine angiography may have a role in left main or complex coronary interventions; however, these findings are exploratory and were not seen in randomized trials. After reviewing the data on routine angiography after coronary revascularization, we came to the conclusion that current data does not support the use of routine angiography for asymptomatic patients. However, there is a lack of randomized controlled trial in this field with only one recent trial reporting negative outcomes.

Invasive “in the cath-lab” assessment of myocardial ischemia in patients with coronary artery disease: When does the gold standard not apply?

International guidelines recommend that revascularization for coronary artery disease (CAD) should be guided by evidence of myocardial ischemia. Fractional flow reserve (FFR) and instantaneous free wave ratio (iFR) are the main invasive indices for assessing the ischemic potential of angiographically intermediate coronary stenosis as a large body of evidence supports their routine application. Both indices have been tested and validated in patients with isolated stable CAD, but notably their application outside this specific context is a matter of debate and investigation. In the present review we aim to look into the available evidence about the reliability and feasibility of FFR and iFR in clinical contexts different from stable angina where these techniques have been validated. We aim to shed light on which technique can be used to invasively assess ischemia when an angiographic moderate coronary stenosis is observed in a clinical setting other than isolated stable CAD.

Angiographic Predictors of Coronary Haemodynamics: The FFR Is Not Affected by Lesion Length or Location

Aims: The use of intracoronary physiological measurement to guide revascularisation for coronary artery disease (CAD) reduces major adverse cardiovascular events. This study investigated whether fractional flow reserve (FFR) values correlate with diameter of stenosis, lesion location, the presence of diffuse coronary disease, and or lesion length.

To Cath or Not to Cath: PCI for Chest Pain in Stable Coronary Artery Disease

Most patients with symptomatic Coronary Artery Disease (CAD) are seeking quick relief for their angina by requesting Percutaneous Coronary Intervention (PCI) that proved to be effective in Acute Coronary Syndrome (ACS), however, their request for PCI may be appropriately denied in stable CAD. Temptations for complete revascularization in CAD make certain valid target for patients as well as their treating physicians; nonetheless, cost effectiveness based on documented outcomes may not support interventional strategy.

4149Coronary CT angiography with selective PET perfusion imaging guides referral for invasive coronary angiography and revascularization in coronary artery disease

4149Coronary CT angiography with selective PET perfusion imaging guides referral for invasive coronary angiography and revascularization in coronary artery disease

CRT-200.30 Three Years Follow-up Of The Eraci IV Registry - A Modified Syntax Score For The Treatment Of Multiple Vessel Disease And Left Main Stenosis

To evaluate the long term efficacy and safety of newer drug eluting stent generations (2-DES) for the treatment of multiple vessel disease and left main stenosis compared to first generation of DES (1-DES) and to validate a new score based in functional revascularization of coronary artery disease

Cardiovascular Lipid Risk Factors and Rate of Cardiovascular Events After Myocardial Revascularization

Abstract Background: Coronary heart disease is a public health problem, and the leading cause of premature death in Europe and worldwide. There is epidemiological evidence that the control of cardiovascular risk factors following myocardial revascularization remains suboptimal. Objectives: Analyze the incidence of cardiovascular events in patients receiving secondary prevention therapies after myocardial revascularization. Methods: Single-center study on consecutive coronary patients retrospectively identified, conducted at the Institute of Cardiovascular Diseases in Timisoara, Romania. Patients with diagnosis of revascularization for coronary artery disease (percutaneous coronary intervention, PCI or coronary artery bypass grafting, CABG) were included, following the inclusion criteria of the EuroAspire IV study. Outcome measures were assessed at three time points- at T0, when myocardial revascularization was performed; at T1 (interview with patients who had undergone revascularization for more than 6 months and less than 5 years), and T2 (interview with patients who had undergone revascularization for more than 5 years). Associations of primary and secondary lipid targets with the rates of adverse cardiovascular events (MACE) were assessed at T2. Results: Of 375 coronary patients, 341 were included in the study. At T1, 5% and 34.9% of patients reached the LDL-c and non-HDL-c target respectively. MACE rate at T2 was 7.9% in a median of 4.33 years of follow-up. We found a positive, statically significant association between MACE rate and LDL-c at T1 (p = 0.039). There were significant differences in mean non-HDLc levels between MACE categories at T1 (p = 0.02). There was a significant association between mean non-HDL with the incidence of heart failure (p = 0.007), newly diagnosed diabetes (p = 0.017) and restenosis rate (p = 0.004). Conclusion: The study highlights the need to control lipid risk factors after myocardial revascularization procedures, even at long-term, to minimize the risk of cardiovascular events in patients with coronary diseases.

COMPARISON OF IN-STENT RESTENOSIS RATES AFTER PERCUTANEOUS CORONARY INTERVENTION IN PATIENTS WITH HEMODIALYSIS VERSUS PERITONEAL DIALYSIS

The establishment of percutaneous coronary intervention (PCI) has dramatically changed revascularization in coronary artery disease. A limitation of PCI is the elopment of in-stent restenosis (ISR), defined as re-narrowing of the stented segment. The rate of clinical ISR for drug-eluting stents (DES) is estimated at 5-10%. A number of clinical risk factors have been identified, including renal disease. End-stage renal disease (ESRD) requiring kidney replacement therapy affects close to 40, 000 Canadians. Cardiovascular mortality accounts for 50% of deaths in this patient population. The mechanisms leading to accelerated atherogenesis is thought to be different in hemodialysis (HD) and peritoneal dialysis (PD) patients, therefore rates of ISR could also be different. The objective is to compare the rates of ISR in HD versus PD patients in Manitoba.

CABG or PCI: which is better for revascularization of coronary artery disease in chronic kidney disease?

Chronic kidney disease (CKD) is a potent risk factor for coronary artery disease and premature death. However, the optimal strategies for revascularization versus medical management remain unclear. Charytan etal. address this knowledge gap with a well-structured individual patient meta-analysis. We discuss the implications of their findings for patients with moderate CKD and highlight the need for randomized, controlled trials on this issue in more severe CKD.

Kidney Function Does Not Modify the Favorable Quality of Life Changes Associated With Revascularization for Coronary Artery Disease: Cohort Study.

BackgroundAlthough patients with kidney disease have potential to benefit from revascularization, they are also at higher risk of complications, which may affect quality of life.Methods and ResultsWe studied a cohort of 8198 adults who underwent coronary angiography in Alberta, between 2004 and 2008, and completed health‐related quality‐of‐life (HR‐QOL) surveys. Changes in HR‐QOL measures were most favorable among patients who received coronary artery bypass graft (CABG), but did not significantly differ by kidney function within groups of patients who received CABG, percutaneous coronary intervention (PCI), or medical therapy (P value for interaction between estimated glomerular filtration rate [eGFR] and revascularization status >0.10 for all outcomes). Among those who received CABG, the adjusted mean EuroQol 5 dimensions (EQ‐5D) utility score for those with eGFR >90 mL/min per 1.73 m2 increased by 0.11 (95% CI, 0.09–0.14) and for those with eGFR <30 mL/min per 1.73m2 by 0.13 (95% CI, 0.05–0.21). The adjusted mean EQ‐5D utility score also increased similarly at all levels of eGFR for those who received PCI and for those who received medical management. Mean changes in Seattle Angina Questionnaire (SAQ) scores were also similar across all levels of eGFR within each treatment group for the quality of life, angina frequency, angina stability, physical limitations, and treatment satisfaction domains of the SAQ. Among those who received CABG, the adjusted mean SAQ quality of life score for those with eGFR >90 mL/min per 1.73m2 increased by 22.1 (95% CI, 18.5–25.7) and for those with eGFR <30 mL/min per 1.73m2 by 14.0 (95% CI, 2.31–25.63).ConclusionsChanges in HR‐QOL do not vary by kidney function among patients selected for CABG, PCI, or medical management of coronary disease.

Impact of incomplete revascularization of coronary artery disease on long-term cardiac outcomes. Retrospective comparison of angiographic and myocardial perfusion imaging criteria for completeness

BackgroundCoronary revascularization in patients with coronary artery disease may be guided by coronary angiography (CA) or alternatively by ischemia on stress myocardial perfusion imaging (MPI). Which strategy leads to optimal cardiac outcomes is uncertain. MethodsWe performed a retrospective analysis of 170 patients with MPI ischemia and percutaneous coronary intervention. The primary endpoint was all-cause mortality at a mean follow-up of 47 ± 21 months; the secondary end point was the composite of deaths, nonfatal myocardial infarction, and repeat coronary revascularization (MACE). The coronary revascularization was defined as complete (CCR) or incomplete (ICR) as judged by CA criteria and by MPI ischemia matched with CA criteria. ResultsNighty-two patients (54%) had ICR by CA criteria (ICR-CA) and 84 (49%) had ICR by MPI criteria (ICR-MPI). Mortality and MACE were lower in patients with CCR-MPI than with ICR-MPI (P = .048, and P = .025). Survival of patients with CCR-CA and ICR-CA was not different (P = .081). Patients with both ICR-MPI and ICR-CA had the worst survival, whereas patients with CCR-MPI and CCR-CA had the best survival (P = .047). By multivariate analysis, ICR-MPI + ICR-CA was an independent predictor of death (P = .025). ConclusionPatients with ICR by MPI were at higher risk than those with CCR. Patients with both ICR by MPI and CA were at the highest risk, while patients with CCR by both MPI and CA had the best long-term event-free survival.

Short- and long-term follow-up after minimally invasive direct coronary artery bypass in octogenarians.

Demographic changes lead to a rising incidence of octogenarians undergoing surgical revascularization of coronary artery disease. Minimally invasive direct coronary artery bypass (MIDCAB) represents a surgical treatment with reduced trauma and without the use of cardiopulmonary bypass. The aim of this study was to evaluate short- and long-term outcomes after MIDCAB in octogenarians. Between 1998 and 2012, 1060 patients underwent MIDCAB at our department. Among them, 72 patients (6.8%) were older than 80 years at the time of operation. Incidence of major adverse cardiac and cerebrovascular events (MACCEs) was compared between octogenarians [median age 82 (81; 85) years, 63.9% male] and younger MIDCAB patients [median age 64 (56; 70) years, 70.7% male] after 30 days and during follow-up. The impact of demographics and preoperative comorbidities on mortality during follow-up was analysed. At baseline, the elderly group presented with a statistically significant higher logistic EuroSCORE I (9.2 vs 2.2%, P < 0.001). Within 30 days, octogenarians showed a mortality rate of 5.6% (younger patients 0.8%, P = 0.006) and an MACCE rate of 5.6% (younger patients 1.3%, P = 0.024). The median follow-up time of 30-day survivors was 5.5 (2.9; 7.6) years and follow-up completeness reached 96.9%. In the elderly group, 1-, 3- and 5-year survival rates were 89, 78 and 63% in comparison with 97, 94 and 90% in the younger group (P < 0.001), respectively. The estimated median survival time in octogenarians was 6.7 (CI 4.854; 8.629) years. Logistic regression showed preoperative renal impairment, peripheral arterial occlusive disease and pulmonary hypertension to have a stronger impact on mortality during follow-up than age above 80 years. MIDCAB represents a safe treatment option in octogenarians and is associated with a good perioperative outcome and satisfying long-term results in octogenarians.

Field Synopsis of Sex in Clinical Prediction Models for Cardiovascular Disease.

Several widely used risk scores for cardiovascular disease (CVD) incorporate sex effects, yet there has been no systematic summary of the role of sex in clinical prediction models (CPMs). To better understand the potential of these models to support sex-specific care, we conducted a field synopsis of sex effects in CPMs for CVD. We identified CPMs in the Tufts Predictive Analytics and Comparative Effectiveness CPM Registry, a comprehensive database of CVD CPMs published from January 1990 to May 2012. We report the proportion of models including sex effects on CVD incidence or prognosis, summarize the directionality of the predictive effects of sex, and explore factors influencing the inclusion of sex. Of 592 CVD-related CPMs, 193 (33%) included sex as a predictor or presented sex-stratified models. Sex effects were included in 78% (53/68) of models predicting incidence of CVD in a general population, versus only 35% (59/171), 21% (12/58), and 17% (12/72) of models predicting outcomes in patients with coronary artery disease, stroke, and heart failure, respectively. Among sex-including CPMs, women with heart failure were at lower mortality risk in 8 of 8 models; women undergoing revascularization for coronary artery disease were at higher mortality risk in 10 of 12 models. Factors associated with the inclusion of sex effects included the number of outcome events and using cohorts at-risk for CVD (rather than with established CVD). Although CPMs hold promise for supporting sex-specific decision making in CVD clinical care, sex effects are included in only one third of published CPMs.

低心機能症例に対する冠血行再建術

低心機能症例に対する冠血行再建術

Reversibility of High-Grade Atrioventricular Block with Revascularization in Coronary Artery Disease without Infarction: A Literature Review.

Complete atrioventricular (AV) block is known to be reversible in some cases of acute inferior wall myocardial infarction (MI). The reversibility of high-grade AV block in non-MI coronary artery disease (CAD), however, is rarely described in the literature. Herein we perform a literature review to assess what is known about the reversibility of high-grade AV block after right coronary artery revascularization in CAD patients who present without an acute MI. To illustrate this phenomenon we describe a case of 2 : 1 AV block associated with unstable angina, in which revascularization resulted in immediate and durable restoration of 1 : 1 AV conduction, thereby obviating the need for permanent pacemaker implantation. The literature review suggests two possible explanations: a vagally mediated response or a mechanism dependent on conduction system ischemia. Due to the limited understanding of AV block reversibility following revascularization in non-acute MI presentations, it remains difficult to reliably predict which patients presenting with high-grade AV block in the absence of MI may have the potential to avoid permanent pacemaker implantation via coronary revascularization. We thus offer this review as a potential starting point for the approach to such patients.

Revascularization heart team recommendations as an adjunct to appropriate use criteria for coronary revascularization in patients with complex coronary artery disease.

To evaluate how a comprehensive evidence-based clinical review by a multidisciplinary revascularization heart team on treatment decisions for revascularization in patients with complex coronary artery disease using SYNTAX scores combined with Society of Thoracic Surgeons-derived clinical variables can be additive to the utilization of Appropriate Use Criteria for coronary revascularization. Decision-making regarding the use of revascularization for coronary artery disease has come under major scrutiny due to inappropriate overuse of revascularization. There is little data in routine clinical practice evaluating how a structured, multidisciplinary heart team approach may be used in combination with the Appropriate Use Criteria for revascularization. From May 1, 2012 to January 1, 2015, multidisciplinary revascularization heart team meetings were convened to discuss evidence-based management of 301 patients with complex coronary artery disease. Heart team recommendations were adjudicated with the Appropriate Use Criteria for coronary revascularization for each clinical scenario using the Society for Cardiovascular Angiography and Interventions' Quality Improvement Toolkit (SCAI-QIT) Appropriate Use Criteria App. Concordance of the Heart Team to Appropriate Use Criteria had a 99.3% appropriate primary indication for coronary revascularization. Among patients who underwent percutaneous revascularization, 34.9% had an inappropriate or uncertain indication as recommended by the Heart Team. Patients with uncertain or inappropriate percutaneous coronary interventions had significantly higher SYNTAX score (27.3 ± 6.6; 28.5 ± 5.5; 19.2 ± 6; P < 0.0001) and Society of Thoracic Surgeons-Predicted Risk of Mortality (6.1% ± 4.7%; 8.1% ± 6.3%; 3.7% ± 4.1%; P < 0.0081) compared to appropriate indications, frequently had concomitant forms of advanced comorbidities and frailty in the setting of symptomatic coronary artery disease. A formal, multidisciplinary revascularization heart team can provide proper validation for clinical decisions and should be considered in combination with the Appropriate Use Criteria for coronary revascularization to formulate revascularization strategies for individuals in a patient-centered fashion. © 2015 Wiley Periodicals, Inc.

Abstract 12749: Impact of Intrastent Yellow Plaque Observed by Coronary Angioscopy at Late Phase After Drug-Eluting Stents Implantation in Clinical Outcome

Background: Previous study showed that number of yellow plaque in a coronary artery was associated with future risk of acute coronary syndrome. However, impact of intrastent yellow plaque has not fully understood. Purpose: This study was investigated to assess the association of the grade of intrastent yellow plaque observed by coronary angioscopy at late phase after drug-eluting stents (DES) implantation and clinical outcome. Methods: This study consisted of 97 patients tread with DES implantation (39 patients with sirolimus-eluting stents ; 9 patients with paclitaxel-eluting stents; 24 patients with everolimus-eluting stents; 6 patients with zotalolimus-eluting stents; 19 patients with biolimus-eluting stents ). Coronary angioscopy was performed 8 months after DES implantation. The plaque color at stent segment was grade as 0 (white), 1 (light yellow), 2 (yellow), 3 (bright yellow). The maximum color grade of the plaques in stent segment was assessed. We divided these patients into 2 groups (53 patients with yellow plaque grade 2 or 3; 44 patients with yellow plaque grade 0 or 1). We evaluated the incidence of revascularization, such as percutaneous coronary intervention or coronary artery bypass graft. Results: Kaplan-Meier curves for 7-year Revascularization free rate are shown in Figure. Revascularization free rate was tend to be higher in patients with yellow grade 0/1 than those with yellow grade 2/3. Conclusion: The presence of intrastent yellow plaque at late phase after stent implantation might be associated with the future revascularization in coronary artery disease.

Relationship of Body Mass Index With Total Mortality, Cardiovascular Mortality, and Myocardial Infarction After Coronary Revascularization: Evidence From a Meta-analysis

ObjectiveTo investigate the relationship of body mass index (BMI) with total mortality, cardiovascular (CV) mortality, and myocardial infarction (MI) after coronary revascularization procedures (coronary artery bypass grafting [CABG] and percutaneous coronary intervention [PCI]). Patients and MethodsSystematic search of studies was conducted using PubMed, CINAHL, Cochran CENTRAL, Scopus, and the Web of Science databases. We identified studies reporting the rate of MI, CV mortality, and total mortality among coronary artery disease patients' postcoronary revascularization procedures in various BMI categories: less than 20 (underweight), 20-24.9 (normal reference), 25-29.9 (overweight), 30-34.9 (obese), and 35 or more (severely obese). Event rates were compared using a random effects model assuming interstudy heterogeneity. ResultsA total of 36 studies (12 CABG; 26 PCI) were selected for final analyses. The risk of total mortality (relative risk [RR], 2.59; 95% CI, 2.09-3.21), CV mortality (RR, 2.67; 95% CI, 1.63-4.39), and MI (RR, 1.79; 95% CI, 1.28-2.50) was highest among patients with low BMI at the end of a mean follow-up period of 1.7 years. The risk of CV mortality was lowest among overweight patients (RR, 0.81; 95% CI, 0.68-0.95). Increasing degree of adiposity as assessed by BMI had a neutral effect on the risk of MI for overweight (RR, 0.92; 95% CI, 0.84-1.01), obese (RR, 0.99; 95% CI, 0.85-1.15), and severely obese (RR, 0.93; 95% CI, 0.78-1.11) patients. ConclusionAfter coronary artery disease revascularization procedures (PCI and CABG), the risk of total mortality, CV mortality, and MI was highest among underweight patients as defined by low BMI and CV mortality was lowest among overweight patients.

New coronary aneurysm formation and malapposition after zotarolimus-eluting stent implantation in Kawasaki disease

Coronary artery involvement is the most important complication of Kawasaki disease. Coronary artery bypass surgery has been performed for ischemic heart disease caused by Kawasaki disease, however, long-term coronary graft patency is not satisfactory. Therefore, percutaneous coronary intervention (PCI) has its role in Kawasaki disease-related coronary artery disease. The incidence of new aneurysm is lower following stent implantation than balloon dilatation alone, even if a higher balloon pressure is applied. However, there are few reports about the efficacy of drug-eluting stent implantation for Kawasaki disease with coronary artery disease. Here, we describe a case of new coronary aneurysm formation and malapposition after zotarolimus-eluting stent implantation in Kawasaki disease.<Learning objective: New aneurysm formation after balloon angioplasty for coronary artery lesions in Kawasaki disease is a relatively well-known phenomenon, however there have been no reports about the influence of drug-eluting stents for coronary artery disease with Kawasaki disease. This report is useful when we consider strategies of revascularization for coronary artery disease with Kawasaki disease.>

Net Reclassification Improvement and Integrated Discrimination Improvement

The role of stress testing in the noninvasive evaluation of patients with possible or known coronary artery disease has evolved from functioning as a diagnostic tool to serving primarily as an aid in risk stratification. The results of clinical assessment and stress testing can be combined to estimate individual patient risk and guide subsequent treatment. National guidelines recommend that stress imaging preferentially be performed instead of standard exercise testing in patients with characteristics consisting of inability to exercise adequately, uninterpretable exercise ECG, or previous coronary artery disease revascularization.1,2 Aside from these patient subsets, controversy persists concerning the selection of a stress test modality attributable to uncertainty concerning the incremental prognostic value of stress imaging compared with standard exercise testing. Article see p 531 For nuclear myocardial perfusion gated SPECT (MPGS), patient risk can be determined simply by dichotomizing images as normal/abnormal,3 but risk stratification can be refined by categorizing the images on the basis of summed perfusion scores.4,5 These scores include the summed stress score, which is a reflection of the extent and severity of combined infarction and ischemia, and the summed different score, an indicator of the extent and severity of ischemia. In this issue of Circulation: Cardiovascular Imaging , Candell-Riera et al6 report on the prognostic value of exercise MPGS in 5672 patients with known or suspected coronary artery disease. The authors apply the c-statistic, net reclassification improvement (NRI), and integrated discrimination improvement (IDI) to examine the incremental prognostic value of MPGS compared with clinical and exercise test variables for predicting the end points of all-cause death and the major cardiovascular end point of combined cardiovascular death and nonfatal myocardial infarction. The authors report 2 major findings: (1) predictive accuracy significantly increased by adding exercise variables to clinical variables for …