Risk Of Coronary Revascularization Research Articles

Efficacy and Safety of Ticagrelor versus Clopidogrel in Dialysis Patients with Coronary Syndromes: A Systematic Review and Meta-Analysis.

(1) Background: The optimal antiplatelet therapy for end-stage kidney disease (ESKD) patients on chronic dialysis presenting with acute or chronic coronary syndromes (ACS or CCS) remains uncertain. This meta-analysis aimed to compare the efficacy and safety endpoints of ticagrelor and clopidogrel in ESKD patients requiring dialysis and presenting with ACS or CCS. (2) Methods: Studies were included comparing ticagrelor and clopidogrel in ESKD patients on chronic dialysis with ACS or CCS. The primary composite efficacy outcome was a combination of all-cause and cardiovascular mortality, recurrent myocardial infarction or coronary revascularization, and ischemic or hemorrhagic stroke. The primary safety outcome was major and non-major bleeding events. (3) Results: Five observational studies met the eligibility criteria. The pooled analysis showed no significant difference in the primary composite efficacy outcome between ticagrelor and clopidogrel (p = 0.40). Similarly, the 2 groups had no significant differences in all-cause mortality (p = 0.82) or cardiovascular mortality (p = 0.79). Ticagrelor did not show a significantly different risk of coronary revascularization (p = 0.35) or recurrent myocardial infarction (p = 0.41) compared to clopidogrel. Also, the risk of stroke was similar (p = 0.21). The 2 groups had no significant difference in the primary composite safety outcome (p = 0.22) or major bleeding events (p = 0.27). (4) Conclusions: In ESKD patients on chronic dialysis with ACS or CCS, there was no significant difference in efficacy or safety outcomes between ticagrelor and clopidogrel. Further randomized controlled trials are needed to establish the optimal antiplatelet therapy in this population.

GLUCAGON-LIKE PEPTIDE-1 RECEPTOR AGONISTS DO NOT DECREASE THE RISK FOR CORONARY REVASCULARIZATION IN PATIENTS WITH TYPE 2 DIABETES: A META-ANALYSIS OF CARDIOVASCULAR OUTCOME TRIALS

Objective: Cardiovascular disease (CVD) is common among subjects with type 2 diabetes mellitus (T2DM), while it represents the main cause of death, accounting for half of deaths in this population. Prevalence of coronary artery disease (CAD) among diabetic subjects is relatively high, more than 20%. Glucagon-like peptide-1 receptor agonists (GLP-1RAs), a class of antidiabetics with established cardiovascular benefits for patients with T2DM, have been shown to decrease the risk for major adverse cardiovascular events, cardiovascular and all-cause mortality, while they have been shown to decrease the risk for fatal or non-fatal myocardial infarction; therefore they have been suggested as second-line treatment option for patients with T2DM and established atherosclerotic cardiovascular disease. Design and method: We searched PubMed from inception to September 1st, 2021, for the relevant cardiovascular outcome trials with GLP-1RAs in patients with T2DM, to pool data concerning coronary revascularization. We searched both published reports and supplementary appendices. We evaluated the surrogate outcome of coronary revascularization with GLP-1RAs versus placebo. Results: We pooled data from 5 trials in a total of 41,355 subjects with T2DM. GLP-1RA treatment compared to placebo did not have a significant effect on the risk for coronary revascularization (risk ratio = 0.95, 95% CI; 0.81 – 1.11, I2 = 77%, p = 0.51). No significant differences were observed during various subgroup analyses. Conclusions: Despite their established cardioprotective effects in high-risk patients with T2DM, GLP-1RAs do not seem to confer a significant risk reduction in terms of coronary revascularization. Additional analyses according to the type of revascularization procedure might provide interesting insights.

The impact of bariatric surgery on the risk of coronary revascularization.

Metabolic surgery is associated with improved cardiovascular risk profile. Randomized and observational studies exploring the impact of bariatric surgery on follow-up coronary revascularization (CR) as a primary endpoint are limited. To identify the impact of metabolic surgery on the risk of follow-up CR, including percutaneous coronary revascularization (PCI) and coronary artery bypass grafting (CABG) SETTING: Stony Brook Department of Surgery, Stony Brook University Hospital, New York, United States. A retrospective analysis was performed for patients with obesity between 2006 and September 2015. Patients were divided into those with history of metabolic surgery and those without. Patient were also stratified by bariatric surgery type. All study groups were followed till 2018 and for at least 3 years to monitor the development of the primary endpoint-any CR including PCI or CABG. The study population with obesity was 515,307 patients; 95,901 with history of surgery versus 419,406 matched patients without. A total of 12,873 (13.4%) with surgery and 51,478 (12.27%) without were lost to follow-up by 2018. The group with history of surgery had a reduced risk of future CR (hazard ratio [HR], .46; 95% confidence interval [CI]: .42-.50; P < .0001), PCI (HR, .45; 95% CI: .41-.49; P < .0001) and CABG (HR, .49; 95% CI:.42-.56; P < .0001). In subgroup analysis, laparoscopic adjustable gastric banding compared with Roux-en-Y gastric bypass (RYGB) was associated with higher follow-up CR (HR, 1.34; 95% CI: 1.11-1.63; P < .01) and PCI (HR, 1.34; 95% CI: 1.07-1.68; P < .05). Bariatric surgery is associated with reduced risk of future CR, PCI, and CABG. Upon subgroup analysis, RYGB was associated with reduced risk of PCI and CR.

Abstract 14770: Reduction With Evolocumab in Complex Coronary Disease Requiring Revascularization: Insights From the FOURIER Trial

Introduction: Although PCSK9 inhibitors induce plaque regression and reduce the risk of coronary revascularization overall, their ability to specifically reduce the risk of complex coronary atherosclerosis requiring revascularization has not been explored. Methods: FOURIER was a randomized trial of the PCSK9 inhibitor evolocumab vs. placebo in 27,564 patients with ASCVD on statin therapy (median achieved LDL-C 32 mg/dL vs. 89 mg/dL) followed for a median of 2.2 years. The study database was blindly reviewed to assess characteristics of coronary revascularization procedures. Complex revascularization was the composite of complex PCI (per GLOBAL LEADERS criteria, at least one of: multivessel PCI, 3 or more stents implanted, 3 or more lesions treated, bifurcation PCI with 2 or more stents, or total stent length &gt;60 mm) or CABG. PCI complications included no-reflow, side branch loss, thrombus formation, major dissection, or perforation. The effects of evolocumab on types of revascularization and PCI complications were evaluated using Cox proportional hazards models. Results: 1724 patients underwent revascularization procedures during follow-up. Evolocumab reduced the risk of non-complex PCI by 22% (HR 0.78; 95%CI 0.70-0.88; P&lt;0.001) and the risk of complex revascularization by 29% (HR 0.71; 95%CI 0.61-0.84; P&lt;0.001), including complex PCI by 33% (HR 0.67; 95%CI 0.54-0.84; P&lt;0.001) and CABG by 24% (HR 0.76; 95%CI 0.60-0.96; P=0.019; Figure). The incidence of reported PCI complications tended to be lower with evolocumab (HR 0.74; 95% CI 0.49-1.11). Conclusions: Adding evolocumab to statin therapy reduced the risk of developing complex coronary disease requiring revascularization, including complex PCI and CABG individually. Together with prior coronary imaging findings, these data suggest very aggressive LDL-C lowering to &lt;1 mmol/L has beneficial effects on coronary atherosclerosis burden, anatomical complexity, and the need for intervention.

P860Adding clinical risk scores to troponin-based rule-out algorithms improves identification of patients at high risk for coronary revascularization within 6 weeks: the WESTCOR study

Abstract Background The ESC 0/3-h and High-STEACS study algorithms using high-sensitive troponin assays have proven effective in ruling out NSTEMI, but the safety of out-of-hospital follow-up of ruled out patients is disputable. Clinical risk scores may help to identify patients who develop major adverse cardiac events (MACE) defined as NSTEMI, death or coronary lesions in need of acute or elective revascularization within six weeks after admittance. Purpose Assess the ability of the ESC and High-STEACS study algorithms alone and in combination with clinical risk scores to identify MACE in unselected patients presenting with chest pain. Methods 985 patients (mean 63 years, 61% male) with suspected NSTE-ACS were consecutively included from Sept. 2015 to Feb. 2017. Serum samples were collected at 0, 3 and 8–12 hours and hs-cTnT and hs-cTnI were measured. The final diagnosis was adjudicated by two independent cardiologists. The troponin-based algorithms where compared to nine clinical risk scores, HEART, CARE, GRACE, T-MACS, TIMI, EDACS, sEDACS, Goldman and Geleijnse. Results The prevalence of NSTEMI during index hospitalization was 13%. The ESC 0/3-h and High-STEACS algorithms missed 3 events of NSTEMI with excellent NPV of 99.5 and 99.6. Rule-out patients with normal ECGs, GRACE score &lt;140 and no residual pain had a prevalence of MACE within 6 weeks of 9% using both algorithms. The most frequent event was non-acute revascularization due to unstable angina pectoris. Three of ten clinical risk scores had higher accuracy than the ESC 0/3-h algorithm for identification of MACE: HEART (AUC 0.84), CARE (AUC 0.79) and T-MACS (AUC 0.76). Combining the ESC 0/3-h rule-out algorithm and HEART≤3 had the best AUC of 0.85, missing only 12 (3%) MACE. Troponin-based algorithms and HEART True pos. True neg. False pos. False neg. NPV PPV Sens. Spes. Prop. low-risk AUC Troponin-based algorithms, endpoint NSTEMI ESC 0/3h TnT 118 628 196 3 99.5 37.6 97.5 76.2 66.8 0.87 High-STEACS TnI 118 715 109 3 99.6 52.0 97.5 86.8 76.0 0.92 Troponin-based algorithms, endpoint MACE ESC 0/3h TnT 143 577 171 54 91.4 45.5 72.6 77.1 66.8 0.75 High-STEACS TnI 130 651 97 67 90.7 57.3 66.0 87.0 76.0 0.77 Troponin-based algorithms combined with HEART score, endpoint MACE ESC 0/3h HEART 3 185 414 334 12 97.2 35.7 94.1 55.4 44.6 0.85 High-STEACS HEART 3 186 411 337 11 97.4 35.6 94.7 55.0 44.7 0.85 Causes of MACE Conclusion The ESC 0/3-h and High-STEACS algorithms identify almost all patients with low risk of NSTEMI, who are candidates for none or out-of-hospital follow-up. However, 9% of ruled out patients have MACE within 6 weeks. The combination of ESC algorithm and clinical risk scores markedly reduce the number of ruled out patients with MACE.

Cardiovascular events and death after myocardial infarction or ischemic stroke in an older Medicare population.

BackgroundSurvivors of myocardial infarction (MI) or ischemic stroke (IS) are at high risk for subsequent cardiovascular events.HypothesisOlder patients with prior MI or IS are at risk for recurrent cardiovascular events, and comorbidities such as diabetes may increase this risk.MethodsTwo cohorts were studied in a retrospective Medicare 20% random sample—a 2008 cohort with up to 6 years of follow‐up (MI, N = 26 460; IS, N = 17 566) and a 2012 cohort with 1 year of follow‐up (MI, N = 26 548; IS, N = 17 728).ResultsIn older patients who survived an event of MI or IS (2012 cohort), 7.2% had a recurrent MI and 6.7% had a recurrent IS in the first year; 32% died. Accounting for multiple recurrent events (2012 cohort), the event rates per 100 patient‐years were 11.6 and 10.2 for the MI and IS cohorts, respectively. Cumulative incidence of recurrence (2008 cohort) increased from 7.7% at 1 year to 14.3% at 6 years for recurrent MI and from 6.7% at 1 year to 13.4% at 6 years for recurrent IS. Comorbid diabetes (2012 cohort) was significantly associated (adjusted risk ratio) with MI recurrence (1.44) and risk of coronary revascularization (1.23) in the MI cohort and with IS recurrence (1.26) in the IS cohort.ConclusionIn this older population with prior MI or IS, high rates of recurrent cardiovascular events and multiple recurrent events were observed. These findings highlight the need for aggressive intervention for secondary prevention and management of comorbidities in high‐risk patients, particularly those with diabetes.

The significance of post-stress decrease in left ventricular ejection fraction in patients undergoing regadenoson stress gated SPECT myocardial perfusion imaging

The significance of post-stress decrease in left ventricular ejection fraction (LVEF) with regadenoson stress gated SPECT (GSPECT) myocardial perfusion imaging (MPI) has not been studied. Consecutive patients who underwent rest/regadenoson stress GSPECT-MPI followed by coronary angiography within 6 months were analyzed. Change in LVEF by GSPECT-MPI was calculated as stress LVEF minus rest LVEF; a significant decrease was tested at 5% and 10% thresholds. In a diagnostic cohort of 793 subjects, LVEF change was not predictive of severe/extensive coronary artery disease (area under the curve, 0.50; 95% confidence interval, 0.44-0.57; P=0.946). There was no significant difference in the rates of severe/extensive coronary artery disease in patients with or without a decrease in LVEF, irrespective of MPI findings. In an outcome cohort of the 929 subjects followed for 30 ± 16 months, post-regadenoson stress decrease in LVEF was not associated with increased risk of the composite endpoint of cardiac death or myocardial infarction or in the risk of coronary revascularization. In patients selected to undergo coronary angiography following regadenoson stress GSPECT-MPI, a decrease in LVEF after regadenoson stress is not predictive of severe/extensive CAD or adverse clinical outcomes, irrespective of MPI findings.

Single-centre cohort study of gender influence in coronary CT angiography in patients with a low to intermediate pretest probability of coronary heart disease

BackgroundIn ‘real-world’ patient populations undergoing coronary CT angiography (CCTA), it is unclear whether a correlation exists between gender, coronary artery calcium (CAC) score and subsequent referral for invasive coronary angiography...

Cardiovascular effects of B-vitamins and/or N-3 fatty acids: The Su.Fol.Om3 trial

BackgroundMechanisms involved in coronary stenosis evolution are different than those involved in clinical events. Because of differential vascular effects, N-3 polyunsatured fatty acids (PUFA) and B vitamins could have differential effects on different types of cardiovascular clinical events in high-risk patients. MethodsWe analyzed the effects of n-3 PUFA and of B vitamins on both coronary revascularization and on hard coronary events risks in a subgroup of the SU.FOL.OM3 trial, a randomized, double-blind, placebo-controlled secondary prevention trial. Data were analyzed according to the intention-to-treat principle, with the use of Cox proportional-hazards models. ResultsAfter a mean follow-up of 4.2±1.0years among the 1,863 participants with coronary heart disease, 163 coronary revascularizations were performed, and 95 patients experienced a hard coronary event. Neither treatment with n-3 PUFA, nor treatment with B vitamins was associated with any significant effect on the occurrence of hard coronary events. Allocation to n-3 PUFA was not associated with any significant effect on coronary revascularization. However, treatment with B vitamins was associated with a statistically significant 52% increase in the risk of coronary revascularization (multivariate HR: 1.52; 95% CI: [1.11–2.10]; p=0.01). ConclusionsNeither n-3 PUFA, nor B vitamins reduced the rates of hard coronary events and of coronary revascularization. Furthermore, B vitamins significantly increased the rate of coronary revascularization. Consistent with the findings of previous trials, our results do not support the routine use of dietary supplements containing n-3 PUFA and argue against using dietary supplements containing B-vitamins in coronary patients in secondary cardiovascular prevention.

Cardiovascular Risk in Patients With Fasting Blood Glucose Levels Within Normal Range

Fasting glucose levels elevated beyond the normal range have been associated with increased cardiovascular risk. However, it is unknown whether this association exists for variations of fasting glucose within the normal range. The present study was conducted using the computerized database of the Sharon-Shomron District of Clalit Health Services. Included in the present study were subjects with fasting glucose levels within the normal range (< 100 mg/dl). We excluded patients with a history of cardiovascular disease or diabetes. The primary outcome was the incidence of coronary revascularization with either percutaneous coronary intervention or coronary artery bypass grafting. The 28,263 participants (age 53.7 ± 12.2 years) were divided into quartiles according to the fasting glucose level (75.4 ± 4.5, 83.6 ± 1.7, 88.9 ± 1.4, and 95.1 ± 2.2 mg/dl). During a mean follow-up of 5.9 ± 0.7 years, 424 subjects required coronary revascularization. A progressive increase was seen in the risk of coronary revascularization as the fasting glucose levels increased within the normal range (hazard ratio 1.73, 95% confidence interval 1.3 to 2.3, p > 0.001, between the fourth and first quartiles). However, this association lost its statistical significance after adjustments for the conventional coronary risk factors (hazard ratio 1.17, 95% confidence interval 0.85 to 1.62, p = 0.328). In conclusion, elevated fasting glucose levels within the normal range were associated with an increased cardiovascular risk. This association was caused by the greater prevalence of the other conventional risk factors and not by the glucose level itself.

A Randomized Trial of Low-Dose Aspirin in the Primary Prevention of Cardiovascular Disease in Women

ABSTRACT As demonstrated in randomized trials, men who take low-dose aspirin have a smaller risk of a first myocardial infarction (MI) but little change in the risk of ischemic stroke. Because less information is available for women, the investigators randomly assigned 39,876 healthy women 45 years of age or older to receive either 100 mg aspirin or placebo on alternate days and followed them up for 10.1 years on average. The primary end point was a combination of major cardiovascular events, including nonfatal MI, nonfatal stroke, and death from cardiovascular causes. The aspirin-treated women and placebo recipients had similar baseline characteristics. At the end of the trial, there was a nonsignificant 9% decrease in a first major cardiovascular event in women taking aspirin. The risk of stroke was reduced by 17% in the aspirin group (relative risk [RR], 0.83; 95% confidence interval [CI], 0.69–0.99). The risk of ischemic stroke was lowered by 24% (RR, 0.76; 95% CI, 0.63–0.93). The risk of hemorrhagic stroke increased, but not significantly. Fatal stroke was similarly frequent in the aspirin and placebo groups. Aspirin had no significant effect on the risk of fatal or nonfatal MI (RR, 1.02; 95% CI, 0.84–1.25) or death from cardiovascular causes (RR, 0.95; 95% CI, 0.74–1.22). Aspirin therapy was associated with a 22% reduction in transient ischemic attacks (RR, 0.78; 93% CI, 0.64–0.94). It had no significant effect on the risk of coronary revascularization or on death from any cause. Aspirin was most beneficial in lowering the risk of major cardiovascular events in former smokers and those who had never smoked. The most consistent benefit was noted in women who were 65 years of age or older when entering the study. Neither vitamin E treatment nor beta-carotene significantly influenced the effects of aspirin on primary or secondary end points. Both gastrointestinal (GI) bleeding and peptic ulcer were significantly more frequent in women taking aspirin than in the placebo group. The RR of GI bleeding requiring transfusion for aspirin-treated women, compared with those given placebo, was 1.4 (95% CI, 1.07–1.83). Hematuria, easy bruising, and epistaxis were frequent in both groups but slightly more so in women taking aspirin. Two aspirin-treated women and 3 given placebo died of GI bleeding. This large primary prevention trial affirmed a lowered risk of stroke in women taking alternate-day aspirin, but this treatment did not substantially alter the risk of MI or cardiovascular death.

Spinal Cord Stimulation for the Treatment of Angina Pectoris.

Spinal cord stimulation (SCS) has been demonstrated to cause clinical improvement in patients with refractory angina pectoris in the number of anginal episodes, in nitroglycerin consumption, in maximal exercise time, in exercise time until angina, in the number of episodes of myocardial ischemia, in the duration of episodes of myocardial ischemia, and in ischemic ST-segment depression at a comparable workload. Double-blind, randomized, placebo-controlled studies have not been performed with SCS. The clinical improvement from SCS occurred despite no improvement in measured regional myocardial blood flow during exercise or in myocardial oxygen consumption as assessed by the heart rate times systolic pressure product at maximal exercise. The mechanisms of clinical improvement by SCS are unclear. SCS must be considered experimental at this time, and it remains a potential therapeutic option for the treatment of refractory angina pectoris in patients unable to have coronary revascularization or at very high risk for coronary revascularization.

Management of coronary heart disease in the elderly

The prevalence of coronary heart disease (CHD) increases rapidly with advancing age and remains the major cause of death among elderly Americans. The number of elderly has doubled in the last 30 years and is projected to continue growing at more than twice the rate of the general population. The resources required in managing CHD in this population will reach astronomical levels during the next few decades and will severely tax our ability to provide adequate medical care to all citizens, unless cost effective diagnostic and therapeutic strategies are developed which do not severely compromise health care. Risk factors for CHD should be identified and modified as early in life as possible. Modification of risk factors begun at advanced age appears to confer benefit, however. Anti-ischemic drug therapy is the treatment of choice for patients with mild or moderate stable angina. Select elderly may be willing to accept the increased risks of coronary revascularization to achieve relief from debilitating angina or prolongation of life. Physicians must use care in planning diagnostic and therapeutic strategies. Quality of life and independence are often more important considerations than longevity in this age group.