Stable Ischemic Heart Disease Research Articles

Nitrates as a Marker of Multiple Co-morbidities and Increased Mortality in Patients Undergoing Percutaneous Coronary Intervention (PCI).

BackgroundNotwithstanding the guideline endorsement of various anti-anginal medications, there is a paucity of data on whether one anti-anginal regimen or medication is superior to another. It is also unknown how anti-anginal medications affect outcomes of elective percutaneous coronary intervention (PCI). To fill this knowledge gap, we investigated an association between commonly used anti-anginal medications and elective PCI outcomes in stable ischemic heart disease (SIHD) patients. MethodsUsing the New York State's (NYS) PCI Reporting System, we reviewed data on 33,568 consecutive patients who underwent non-emergent PCI in 2015. The primary endpoint of this study was all-cause in-hospital mortality. ResultsRegardless of the combination therapy of nitrates with any other non-nitrate anti-anginal therapy, including beta-adrenergic blockers (BB) and/or calcium channel blockers (CCB), nitrate treatment continued to be associated with significantly increased post-elective PCI mortality.ConclusionsIn this large, all-inclusive state-wide contemporary cohort study of SIHD patients, treatment with nitrates, but not beta-blockers, calcium channel blockers, or ranolazine, was associated with increased post-PCI mortality. Utilization of nitrate therapy is likely reflective of advanced disease burden rather than directly related to the specific medication intolerance. Additional studies investigating optimal anti-anginal medical therapy on PCI outcomes are warranted.

Effects of angiotensin II receptor blockers on the course of the disease in patients with stable ischemic heart disease

Highlights. The review synthesizes the results of clinical studies on the use of sartans. This topic is highly relevant due to the antihypertensive, metabolic and organ-protective effect of sartans, which can positively affect the course of coronary atherosclerosis.Abstract. Angiotensin II receptor blockers (sartans) are widely used to treat cardiovascular diseases. This class of drugs has antihypertensive and metabolic effects and organ-protective capabilities. Currently, sartans are of high interest due to their pleiotropic effect: improved lipid metabolism, antidiabetogenic action, nephroprotection, and, as a result, reduced total cardiovascular risk. The article presents an overview of clinical data on the use of sartans in patients with ischemic heart disease, the mechanisms of organ-protective effects and prospects of using this class of drugs for total cardiovascular risk reduction. The following data sources were used: e-Library, ClinicalTrials.gov, PubMed, trialbulletin.com, smartpatients.com, BioPortfolio.com.

Nuclear Cardiology in Women and Underrepresented Minority Populations.

To outline sex-specific features of coronary artery disease (CAD) that should be considered in the assessment of women, including those from ethnic minority populations with suspected stable ischemic heart disease (IHD). Second, to determine the latest nuclear imaging tools available to assess microvascular CAD. Latest studies indicate that women are more likely to have ischemia with no obstructive coronary arteries (INOCA) and paradoxically have worse outcomes. Therefore, the evaluation of women with suspected IHD should include assessing microvascular and epicardial coronary circulation. The prevalence of CAD is increasing in younger women due to the increased cardiovascular disease (CVD) risk burden. CAD is often underrecognized in these patients. There is increasing recognition that INOCA is not benign and should be accurately diagnosed and managed. Nuclear imaging assesses the full spectrum of CAD from microvascular CAD to multivessel obstructive epicardial CAD. Further research on myocardial blood flow (MBF) assessment with PET MPI is needed.

Science, Medicine, and the Anesthesiologist

Science, Medicine, and the Anesthesiologist

IGFBP7 Concentration May Reflect Subclinical Myocardial Damage and Kidney Function in Patients with Stable Ischemic Heart Disease.

The objective of this study was to determine the associations between insulin-like growth-factor-binding protein 7(IGFBP7) concentrations and concentrations of troponin T(TnT), N-terminal pro-B-type natriuretic peptide(NT-proBNP) and the parameters of kidney function in patients with stable ischemic heart disease(IHD). The IHD group consisted of 88 patients, and the population group comprised 66 subjects without a history of IHD. IGFBP7, TnT and NTproBNP concentrations were measured. The IGFBP7 value was considerably higher in the IHD group (1.76 ± 1 ng/mL vs. 1.43 ± 0.44 ng/mL, respectively, p = 0.019). Additionally, IHD subjects had a significantly higher concentration of TnT and NTproBNP. In both groups there was a significant correlation between IGFBP7 and serum parameters of kidney function (creatinine concentration: population gr. r = 0.45, p < 0.001, IHD gr. r = 0.86, p < 0.0001; urea concentration: population gr. r = 0.51, p < 0.0001, IHD gr. r = 0.71, p < 0.00001). No correlation between IGFBP7 and microalbuminuria or the albumin to creatinine ratio in urine was found. Moreover, there was a significant correlation between IGFBP7 concentration and markers of heart injury/overload-TnT and NT-BNP(r = 0.76, p < 0.001 and r = 0.72, p < 0.001, respectively). Multivariate regression analysis in joint both revealed that the IGFBP7 concentration is independently associated with urea, creatinine and TnT concentrations (R2 for the model 0.76). IHD patients presented significantly higher IGFBP7 concentrations than the population group. Elevated IGFBP7 levels are associated predominantly with markers of kidney function and myocardial damage or overload.

Revascularization Strategies in Patients with Diabetes and Acute Coronary Syndromes.

To review the current evidence for coronary revascularization in patients with diabetes mellitus (DM) in the setting of an acute coronary syndrome (ACS). In patients with DM and stable multivessel ischemic heart disease, coronary artery bypass graft surgery (CABG) has been observed to be superior to percutaneous coronary intervention (PCI) in long-term follow-up, leading to lower rates of all-cause mortality, myocardial infarction, and repeat revascularization. In the ACS setting, PCI remains the most frequently performed procedure. In patients with an ST-segment-elevation myocardial infarction (STEMI), primary PCI should be the revascularization method of choice, whenever feasible. Controversy still exists regarding when and how to deal with possible residual lesions. In the non-ST-segment-elevation (NSTE) ACS setting, although there are no data from randomized controlled trials (RCTs), recent observational data and sub-analyses of randomized studies have suggested that CABG may be the preferred approach for patients with DM and multivessel coronary disease. There is a paucity of RCTs evaluating revascularization strategies (PCI and CABG) in patients with DM and ACS. CABG may be a viable strategy, leading to improved outcomes, especially following NSTE-ACS.

Correlation between circulating microRNA and lipid indicesin patients with ischemic heart disease and type 2 diabetes mellitus

The aim of the study was to investigate circulating miRNAs-27a, -221 levels and their correlations with lipid indices in patients with ischemic heart disease (IHD) and type 2 diabetes mellitus. Materials and methods. The study included 58 patients with stable IHD and type 2 diabetes mellitus, 22 IHD patients without diabetes and 19 healthy controls. MicroRNAs-27a-3р and 221-3р were determined in blood plasma by real time polymerase chain reaction. U6 small nuclear RNA was used for normalization. Results. The lowest levels of circulating miRNAs-27a and -221 were in IHD patients with diabetes. The decrease in the levels of both microRNAs in patients with diabetes was significant not only in comparison with the control group (P = 0.024, P = 0.006), but also with patients without diabetes (P = 0.011, P = 0.001). In IHD patients without diabetes, microRNAs-27a and -221 levels did not change significantly. In IHD patients with diabetes, microRNA-221 showed a significant positive correlation with high-density lipoprotein cholesterol (HDL-C) (R = 0.382, P = 0.003). MicroRNA-27a was correlated negatively with triglycerides (TG) (R = -0.284, P = 0.051) and positively – with HDL-C (R = 0.257, P = 0.078) at a borderline significance level. The lower level of microRNA-27a (the 1st tertile) was associated with significantly increased TG level in comparison with the 3rd tertile (P = 0.004), and significantly decreased HDL-C level in comparison with the 2nd (P = 0.001) and the 3rd (P = 0.023) tertiles. Patients with lower microRNA-221 level (the 1st tertile) had significantly reduced HDL-C level in comparison with the 3rd tertile(P = 0.007). Conclusions. The results have demonstrated the significant decrease in circulating microRNAs-27a and -221 levels in IHD patients with type 2 diabetes mellitus and no change in both microRNAs in patients without diabetes. In IHD patients with diabetes, the lower expression of microRNA-27a was associated with the significant elevation of TG and the significant decrease in HDL-C. The lower microRNA-221 level was associated only with the significant decrease in HDL-C.

The Neutrophil Lymphocyte Ratio (NLR); recycled as Predictor of Angiographic Coronary Artery Disease Severity in stable Ischaemic Heart Disease

Background: The Neutrophil lymphocyte ratio (NLR) is historically well established in predicting inflammatory process and severity, including atherosclerotic disease. We explore the NLR and how it relates to angiographic coronary artery disease (CAD) severity in patients with stable ischemic heart disease (SIHD). Materials and Methods: We identified 714 patients with SIHD from the local database of Benghazi Medical Centre (BMC) between Jan 2019-June 2020. Exclusion criteria included patients with acute coronary syndromes (ACS), surgical revascularization, moderate-severe left ventricle systolic dysfunction (LVSD) with Ejection fraction less than 45% or New York Heart Association (NYHA) class III-IV. We also excluded patients with significant co-morbidities including chronic kidney disease with glomerular filtration rate (GFR &lt;30), liver cirrhosis, cancer and systemic inflammation requiring long-term steroid therapy. We present a retrospective, cross-sectional study of 427 patients with known SIHD, we explored the relationship between the NLR and the angiographic severity of CAD, using the Gensini score (GS). The association was assessed using correlation analysis and bivariate logistical regression. Results: Patients were categorized into two groups according to the GS, a mild-moderate group (n=178; 41.7%) and a severe group (n=249; 58.3%). A baseline NLR was measured by dividing the Neutrophil count over the Lymphocyte count. In the first group of mild-moderate GS, 160 (89.9%) had an NLR within normal range and 18 (10.1%) demonstrated a high NLR value. However, in the severe GS group 17 (6.8%) showed a normal NLR and 232 (93.2%) demonstrated a high NLR (CI 95%, p=0.0001). Moreover, the distribution of severe GS CAD had a statistically significant overlap with diabetes being the number one risk factor (p=0.0001) when compared to age above 50 (p=0.024). Conclusion: NLR is a valuable independent predictor of the severity of CAD and seems to be a reliable indicator for cardiac risk stratification in patients with SIHD, therefore can potentially be added as a prioritization tool for cardiac angiography.

Клінічні особливості поєднаного перебігу стабільної ішемічної хвороби серця та цукрового діабету

Мета. Вивчення особливостей перебігу та клініки стабільної ішемічної хвороби серця (СІХС), поєднаної з цукровим діабетом (ЦД) 2-го типу. Матеріали та методи. Діагноз «ішемічна хвороба серця: стабільна стенокардія напруження» верифікували за наказом МОЗ України № 152 від 02.03.2016. Діагноз «цукровий діабет 2-го типу» встановлювали відповідно до наказу МОЗ України № 1118 від 21.12.2012. Функціональний клас (ФК) стенокардії напруження оцінювався за рекомендаціями Канадської асоціації кардіологів. Контрольну групу становили 15 практично здорових осіб, репрезентативних за віком і статтю. Рівень ліпідів плазми крові визначали за допомогою наборів фірми Lachema. Статистичний аналіз проводили з використанням пакета програм Statistica for Windows 12.0 (USA). Результати. Обстежено 90 пацієнтів: 30 хворих на стабільну ІХС: стенокардія напруження, ФК ІІ–ІІІ (група І), і 60 хворих на стабільну ІХС: стенокардія напруження, ФК ІІ–ІІІ, та ЦД 2-го типу, інсуліннепотребуючий (група ІІ). Пацієнти обох груп скаржилися на кардіалгії та перебої в роботі серця, задуху, набряки, запаморочення, біль і оніміння нижніх кінцівок, функціональні порушення нервової системи, полідипсію, поліурію, ніктурію. Пацієнти із СІХС та ЦД 2-го типу для зменшення болю за грудниною приймали більше 5 таблеток нітрогліцерину на добу (р &lt; 0,05). У хворих на СІХС незалежно від супутньої патології рівні загального холестерину, тригліцеридів та холестерину ліпопротеїдів низької щільності (ЛПНЩ) були вищими, ніж у групі контролю. Висновки. Супутній ЦД 2-го типу обтяжує перебіг стенокардії напруження, про що свідчать виражена клінічна симптоматика, більша потреба в нітратах, функціональні зміни нервової системи та органів травлення. Ліпідограма хворих на ЦД 2-го типу та стенокардію характеризується вірогідним зростанням рівня тригліцеридів і холестерину ЛПНЩ, що є непрямою ознакою прогресування атеросклеротичного процесу.

Association of Severity of Coronary Artery Disease with Left Ventricular Diastolic Dysfunction among Diabetics with Stable Ischaemic Heart Disease: A Cross-sectional Study from Odisha, India

Introduction: Ischaemic Heart Disease (IHD) is one of the most common co-morbidity among Indian population, so is Diabetes Mellitus (DM). IHD is associated not only with systolic, but also with Diastolic Dysfunction (DDFx) of Left Ventricle (LV). However, there is scarcity of data correlating the severity of Coronary Artery Disease (CAD) with LV DDFx. Aim: To assess the severity of CAD in diabetic stable IHD patients with normal LV systolic function (LV Ejection fraction ≥50%) and it’s association with degree of DDFx. Materials and Methods: A prospective cross-sectional study was conducted over a period of one year, in a tertiary care hospital of Odisha, India among diabetic stable IHD patients. Grades of DDFx were assessed among the study population, using Transthoracic Echocardiography (TTE). Subsequently, severity of CAD was assessed, using invasive Coronary Angiography (CAG) using The SYNergy between percutaneous coronary intervention with TAXus and cardiac surgery (SYNTAX) score. Next, grades of DDFx were correlated with severity of IHD. Results: Among a total of 93 diabetic stable IHD patients with normal LV ejection fraction, 76.3% were males and the mean age was 60.7±8.9 years. Majority presented with chronic stable angina (59, 63.4%). Hypertension (50, 53.7%), followed by dyslipidaemia (36, 38.7%) and renal dysfunction (19, 20.4%) were the most common co-morbidities. Majority of patients had grade I (39.8%), followed by grade II (17.2%), and grade III (9.7%) DDFx. On invasive CAG, 39.8% had a SYNTAX score of ≤ 22, 36.6% had a score of 23-32, and 23.6% had a score of ≥33. Grades of DDFx were found to be significantly higher among the patients with greater SYNTAX score. Conclusion: Among diabetic stable IHD patients, greater the severity of CAD on CAG, higher were the grades of DDFx

Comparative Analysis of the Quality of Life Scales Parameters in Patients with Combination of Stable Ischemic Heart Disease and Metabolic Syndrome

Modern epidemiological studies confirm that comorbid diseases and conditions can have significant impact on diagnostic and treatment of the underlying disease. The problem of the comorbidy of stable coronary heart disease (SCHD) and metabolic syndrome (MS) has high medical and social significance, need high costs for diagnosis and treatment, and leads to decreased of quality of life (QOL). QOL is an important indicator of the health status of patients, which comprehensively characterizes human physical, psychological, emotional and social functioning. The objective: to conduct a comparative analysis of the QOL of patients with combination of SCAD and MS versus patients with isolated SCHD. Materials and methods. The study included 102 patients: 52 people with MS in combination with SCAD and 50 patients with SCHD only. There were 42 (51.2%) men (mean age 49.8 ± 5.3 years), and 40 (48.8%) women (mean age 51.6 ± 6.7 years). The QoL score was assessed by general medical questionnaire – the Medical Outcomes Study 36-Item (SF-36), in which all scales form two indicators: mental and physical health and a specialized questionnaire for patient with stable angina pectoris – SAQ (Seattle Angina Questionnaire). The diagnosis of SCHD with functional class (FC) assessment was performed by European Society of Cardiology criteria. MS was established if three out of five diagnostic criteria were met. Results. Patients with comorbid MS and SCHD demonstrated significantly lower QoL scores, both in psychological and physical components of health (according to the SF-36 questionnaire) compared to patients with SCHD alone (p &lt;0.05). An analysis of the SAQ questionnaire data also showed significantly lower points in group of patients with NAS and SCHD combination compared to the group of patients with isolated SCHD (in total, by 8.76%; p &lt;0.05). Conclusion. Patients with metabolic syndrome in combination with stable coronary heart disease (SCHD) had a statistically significantly lower level of quality of life according to the evaluation by both SF-36 nonspecific questionnaire and the SAQ specific questionnaire comparing to group of patients with isolated SCAD.

Ischemia and no obstructive coronary arteries in patients with stable ischemic heart disease

A large proportion of patients with suspected obstructive coronary artery disease (CAD) is found to have ischemia with no obstructive coronary artery disease (INOCA). Based on current evidence, these patients are at increased risk of adverse cardiovascular events, even though they have no obstructive CAD. Importantly, INOCA is associated with recurrent clinical presentations with chest pain, impaired functional capacity, reduced health-related quality of life, and high healthcare costs. Underlying coronary microvascular dysfunction (CMD), through endothelium-dependent and independent mechanisms contribute to these adverse outcomes in INOCA. While non-invasive and invasive diagnostic testing has typically focused on identification of obstructive CAD in symptomatic patients, functional testing to detect coronary epicardial and microvascular dysfunction should be considered in those with INOCA who have persistent angina. Current diagnostic methods to clarify functional abnormalities and treatment strategies for epicardial and/or microvascular dysfunction in INOCA are reviewed.

Revascularization or Optimal Medical Therapy for Stable Ischemic Heart Disease: A Bayesian Meta-Analysis of Contemporary Trials

BackgroundThe role of revascularization in patients with stable ischemic heart disease (SIHD) has been controversial, more so in the present era of drug-eluting stents. AimsTo examine the absolute risk difference (ARD) between revascularization plus optimal medical therapy (OMT) versus OMT alone among patients with SIHD using Bayesian approach. MethodsPubMed/MEDLINE and Cochrane citation indices were utilized to identify randomized controlled trials (RCTs) through March 31, 2020. Among trials comparing initial revascularization plus OMT with initial OMT alone, revascularization arm must have comprised >50% of patients receiving either percutaneous or surgical revascularization, and >50% of patients must have received aspirin and statin as OMT in both arms. ResultsSeven RCTs (12,494) were included in the final analysis. The ARD of all-cause mortality for revascularization with respect to OMT was centred at −0.002 (95% CrI: −0.01; 0.01, Tau: 0.01, 67% probability of ARD of revascularization vs. OMT < 0). The ARD for cardiac mortality was centred at −0.0025 (95%CrI: −0.01; 0.01, Tau: 0.01, 77% probability of ARD of revascularization vs. OMT < 0). The ARD for MI was −0.02 (95% CrI: −0.06; 0.00, Tau: 0.02, 97% probability of ARD for revascularization vs. OMT < 0). There was 96% probability of ARD for unstable angina with revascularization vs. OMT < 0, 4.5% probability of ARD for freedom from angina with revascularization vs. OMT < 0, and 6% probability of ARD for stroke with revascularization vs. OMT < 0. ConclusionsBayesian analysis demonstrated minimal probability of difference in all-cause mortality and cardiac mortality in patients with SIHD who underwent revascularization compared with OMT alone. However, revascularization was associated with lower probability of MI, unstable angina, and increased freedom from angina, but a higher risk of stroke compared with OMT alone. PROSPEROThe protocol of this systematic review and meta-analysis was registered in PROSPERO [CRD42020160540].

18F-Sodium fluoride uptake is associated with severity of atherosclerotic stenosis in stable ischemic heart disease

BackgroundIncreased uptake of 18F-Sodium fluoride (18F-NaF) PET has potential to identify atherosclerotic plaques that are vulnerable to rupture. Whether 18F-NaF PET can evaluate the significance of atherosclerotic plaque in patients with stable coronary artery disease is less clear. We evaluated 18F-NaF PET uptake in coronary arteries in patients without acute coronary artery syndrome to determine the association of 18F-NaF signal uptake with severity of coronary stenosis. Methods and ResultsWe retrospectively identified 114 patients who received both regadenoson stress 82Rb myocardial perfusion PET and 18F-NaF PET study with an average interval of 5 months. Out of this cohort, forty-one patients underwent invasive coronary angiography. In a patient-based analysis, patients with ischemic regadenoson stress 82Rb PET had significantly higher coronary 18F-NaF uptake than patients with normal myocardial perfusion (P < .01). Among the 41 patients who underwent coronary angiography, per-vessel 18F-NaF uptake in both obstructive and nonobstructive coronary arteries was significantly higher than in normal coronary arteries (P < .05) regardless of the severity of coronary calcification. There was poor correlation between calcification and 18F-NaF uptake in coronary arteries (r = 0.41) ConclusionCoronary arterial 18F-NaF uptake is associated with coronary stenosis severity in patients with stable coronary artery disease. 18F-NaF PET studies may be useful for characterizing coronary atherosclerotic plaques.

Revascularization strategies in patients with diabetes and stable ischemic heart disease: a systematic review and meta-analysis of randomized trials.

The optimal treatment strategy comparing invasive revascularization versus optimal medical therapy (OMT) in patients with diabetes mellitus (DM) and stable ischemic heart disease (SIHD) still remains unclear. We aimed to investigate clinical outcomes of invasive revascularization (percutaneous coronary intervention, coronary artery bypass grafting or both) versus OMT in patients with DM and SIHD from updated published randomised-controlled trials (RCTs). We conducted a comprehensive literature search through PubMed and EMBASE to investigate the effect of revascularization versus OMT for patients with DM and SIHD. The studies were limited to RCTs or their subgroup data for a meta-analysis. The outcomes of interest were major adverse cardiovascular events (MACE) in patients with DM and SIHD. Our search identified subgroup data with DM of four RCTs including a total of 5742 patients with SIHD. Our results showed that invasive revascularization was not associated with a decreased risk of MACE when compared to OMT [hazard ratio (95% confidence interval): 0.95 (0.85-1.05), P = 0.31; I2 = 0%]. Invasive revascularization was not associated with a decreased risk of MACE when compared with OMT.

What is the current value of beta-adrenoreceptor antagonists for angina?

Ischemic heart disease is one of the leading causes of mortality worldwide [1]. Management of patients with stable ischemic heart disease involves risk modification, anti-platelet therapy, anti-ang...

Regulatory T-Cell Response to Low-Dose Interleukin-2 in Ischemic Heart Disease

BackgroundAtherosclerosis is a chronic inflammatory disease of the artery wall. Regulatory T cells (Tregs) limit inflammation and promote tissue healing. Low doses of interleukin (IL)-2 have the potential to increase Tregs, but its use is contraindicated for patients with ischemic heart disease.MethodsIn this randomized, double-blind, placebo-controlled, dose-escalation trial, we tested low-dose subcutaneous aldesleukin (recombinant IL-2), given once daily for 5 consecutive days. In study part A, the primary end point was safety, and patients with stable ischemic heart disease were randomly assigned to receive placebo or to one of five dose groups (range, 0.3 to 3.0 × 106 IU daily). In study part B, patients with acute non-ST elevation myocardial infarction or unstable angina were randomly assigned to receive placebo or to one of two dose groups (1.5 and 2.5 × 106 IU daily). The coprimary end points were safety and the dose required to increase circulating Tregs by 75%. Single-cell RNA-sequencing of circulating immune cells was used to provide a mechanistic assessment of the effects of aldesleukin.ResultsForty-four patients were randomly assigned to either study part A (n=26) or part B (n=18). In total, 3 patients withdrew before dosing, 27 received active treatment, and 14 received placebo. The majority of adverse events were mild. Two serious adverse events occurred, with one occurring after drug administration. In parts A and B, there was a dose-dependent increase in Tregs. In part B, the estimated dose to achieve a 75% increase in Tregs was 1.46 × 106 IU (95% confidence interval, 1.06 to 1.87). Single-cell RNA-sequencing demonstrated the engagement of distinct pathways and cell–cell interactions.ConclusionsIn this phase 1b/2a study, low-dose IL-2 expanded Tregs without adverse events of major concern. Larger trials are needed to confirm the safety and to further evaluate the efficacy of low-dose IL-2 as an anti-inflammatory therapy for patients with ischemic heart disease. (Funded by the Medical Research Council, the British Heart Foundation, and others; ClinicalTrials.gov number, NCT03113773)

OR8. Appropriateness of percutaneous coronary intervention procedure in Indonesia

Abstract Background and Aims There is a possibility of the high variability of the appropriateness of PCI performed in Indonesia. It is assumed that appropriate PCI tends to have clinical outcomes than other categories. This study aimed to evaluate the appropriateness of the percutaneous coronary intervention (PCI) procedure in Indonesia. Method and Results We assigned appropriateness ratings to 214 acute coronary syndromes (ACS) and 191 stable ischemic heart disease (SIHD) records that underwent PCI in four hospitals from 2017 - 2018. The included hospitals consist of one public and three private hospitals, two cardiovascular centers, and two general hospitals with the most performed PCI procedures on 2016 - 2018 and accessible to the researchers. The PCI appropriateness was adjudicated using 2016/2017 ACC/AHA guidelines of the Appropriate Use of Care (AUC) for coronary revascularization in ACS and SIHD. The results were categorized into “appropriate”, “maybe appropriate”, and “rarely appropriate”. The result from this study demonstrated that in ACS patients, 76.0% and 24.0% of PCI were appropriate” and “maybe appropriate”. While, in SHID patients, 68.7%, 28.7%, and 2.6% of PCI were “appropriate”, “maybe appropriate”, and “rarely appropriate”. In ACS patients, “appropriate” PCI is more commonly found in ST-elevation myocardial infarction (STEMI) cases (62.6%). In SIHD patients, 54.0% and 46.0% of left-main diseases patients underwent “maybe appropriate” and “rarely appropriate” PCI. Conclusion The majority of PCI performed in ACS and SIHD patients from the studied hospitals are “appropriate”.

Abstract 14315: Invasive versus Conservative Strategy for Stable Coronary Artery Disease in Patients With Asymptomatic Heart Failure With Reduced Ejection Fraction

Introduction: In asymptomatic heart failure patients with reduced ejection fraction (HFrEF), an ischemia evaluation is part of the routine diagnostic work up. Nonetheless, in asymptomatic HFrEF patients with stable ischemic heart disease (SIHD) and intermediate to high-risk findings on nuclear perfusion study, the decision to pursue conservative medical therapy versus an early invasive strategy remains debatable. To address this conundrum, we performed a retrospective analysis. Method: A total of 451 patients with SIHD and HFrEF were followed for at least 16 months. All patients were classified as intermediate to high-risk based on their nuclear stress test results. Patients were subsequently dichotomized into two groups depending on whether they underwent an initial invasive approach versus continuing conservative medical therapy. A multivariable Cox regression analysis was performed to compare the primary outcome of all-cause mortality between the two groups. Results: Patients undergoing an initial invasive strategy were younger (68.3 ± 11.5 vs 71.3 ± 11.8 years, P = 0.001) and more likely to have a prior percutaneous coronary intervention (PCI, 50% ± 25.9% vs. 35% ± 13.6%, P = 0.001) compared to the medical therapy group. On multivariable analysis, after adjusting for demographics and confounding factors, there was no difference in all-cause mortality between the two groups (p= 0.120, Figure ). An older age with a prior history of a PCI or a cerebrovascular accident (CVA) were independent predictors of mortality while a history of never smoking was associated with a mortality benefit. Conclusions: In asymptomatic HFrEF patients with SIHD with intermediate to high-risk findings on nuclear stress testing, an initial invasive strategy has no significant mortality benefit when compared to medical therapy. An older age, history of prior PCI or CVA predicted mortality while never smoking provided a mortality benefit.

Abstract 12872: Adherence to Guidelines for Heart Rate in Stable Ischemic Heart Disease in the Primary Care Setting

Per 2012 ACC/AHA Guidelines, patients with stable ischemic heart disease (IHD) should be treated with beta-blockers (BB) to target a resting heart rate (HR) of 55-60 bpm due to associations of higher HR with all-cause mortality. We sought to determine adherence to this in the resident primary care (PC) clinic at our institution. Two hundred twenty-nine patients with a medication list in the electronic medical record (EMR) that includes metoprolol succinate or tartrate or carvedilol who were seen in PC clinic in January 2020 were identified. Of these, 100 had a diagnosis of IHD, and their EMR were reviewed for vital signs; medication changes; and contraindications (CI) to BB titration such as hypotension, bradycardia, and max dosing; during their PC and cardiology visits. We found that 10% (10 of 100) had HR within goal during their PC visit, whereas 6 and 84 had HR below and above goal, respectively. Of the 90 whose HR was not at goal, 24 had some perceivable CI to BB titration. Of those without CI to titration, 9% (6 of 66) had their BB increased, 4.5% (3 of 66) had their BB switched to a different medication, and 85% (56 of 66) did not have their BB changed. Of those whose BB was unchanged, 79% (44 of 56) had no other antihypertensive changed. Moreover, 88% (74 of 84) of those with HR above goal had a HR also above goal at their last two PC visits. Sixty-eight of the 100 patients with IHD were also managed by cardiology, and in contrast, 18% (8 of 45) of those with HR not at goal and without CI to titration had their BB dose adjusted at their last cardiology visit. A chi-square test was performed to examine the relation between BB titration and clinic setting with no statistical significance, X 2 (1, N = 106) = 1.18, p = 0.28. In sum, adherence to guidelines for HR in stable IHD were poor and not significantly different in the PC and cardiology settings. Lack of provider initiative, perhaps due to trainee unfamiliarity with guidelines, may be one of many factors and warrants more investigation to improve quality of care.