Stents Versus Coronary Artery Bypass Research Articles

Percutaneous Coronary Intervention With a Drug-Eluting Stent Versus Coronary Artery Bypass Grafting in Patients Receiving Dialysis: A National Study From Taiwan

Rationale & ObjectiveTo study the comparative effectiveness of percutaneous coronary intervention with drug-eluting stent and coronary artery bypass grafting in dialysis patients. Study DesignRetrospective observational cohort study. Setting & ParticipantsThis population-based study identified dialysis patients hospitalized for coronary revascularization between January 1, 2009 and December 31, 2015 in Taiwan National Health Insurance Research Database. ExposuresPercutaneous coronary intervention with drug-eluting stent versus coronary artery bypass grafting. OutcomesAll-cause mortality, in-hospital mortality, and repeat revascularization. Analytical ApproachPropensity scores were used to match patients. Cox proportional hazards models and logistic regression models were constructed to examine associations between revascularization strategies and mortality. Interval Cox models were fit to estimate time-varying hazards during different periods. ResultsA total of 1,840 propensity score-matched dialysis patients were analyzed. Coronary artery bypass grafting was associated with higher in-hospital mortality (coronary artery bypass grafting vs. percutaneous coronary intervention with drug-eluting stent, crude mortality rate 12.5% vs. 3.3%; adjusted odds ratio 5.22; 95% confidence interval [CI] 3.42-7.97; p < 0.001), and longer hospitalization duration (median [interquartile range], 20 [14-30] days vs. 3 [2-8] days, p < 0.001). After discharge, repeat revascularization, acute coronary syndrome, and repeat hospitalization all occurred more frequently in the percutaneous coronary intervention with drug-eluting stent group. Importantly, with a median follow-up of 2.8 years, coronary artery bypass grafting was significantly associated with a higher risk of all-cause overall mortality (adjusted hazard ratio 1.19, 95% CI 1.05-1.35, p = 0.006) in the multivariable Cox proportional hazard model. Sensitivity and subgroup analyses yielded consistent results. LimitationsObservational study with mainly Asian ethnicity. ConclusionsPercutaneous coronary intervention with drug-eluting stent may be associated with better survival than coronary artery bypass grafting in dialysis patients. Future studies are warranted to confirm this finding. Plain Language SummaryAlthough in the general population coronary artery bypass grafting offers better long-term survival than percutaneous coronary intervention with drug-eluting stent, dialysis patients may be too frail to tolerate the increased perioperative mortality risk of coronary artery bypass grafting. In this retrospective study in a national cohort of Taiwan dialysis patients, percutaneous coronary intervention with drug-eluting stent is associated with lower in-hospital mortality and better long-term survival when compared with coronary artery bypass grafting. Subsequent acute coronary syndrome, repeat revascularization, and re-hospitalization developed more frequently in the percutaneous coronary intervention with drug-eluting stent group. These findings may suggest percutaneous coronary intervention with drug-eluting stent as a safe revascularization strategy for dialysis patients.

Can Machine Learning Aid the Selectionof Percutaneous vs SurgicalRevascularization?

In patients with 3-vessel coronary artery disease (CAD) and/or left main CAD, individual risk prediction plays a key role in deciding between percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG). The aim of this study was to assess whether these individualized revascularization decisions can be improved by applying machine learning (ML) algorithms and integrating clinical, biological, and anatomical factors. In the SYNTAX (Synergy between PCI with Taxus and Cardiac Surgery) study, ML algorithms (Lasso regression, gradient boosting) were used to develop a prognostic index for 5-year death, which was combined, in the second stage, with assigned treatment (PCI or CABG) and prespecified effect-modifiers: disease type (3-vessel or left main CAD) and anatomical SYNTAX score. The model's discriminative ability to predict the risk of 5-year death and treatment benefit between PCI and CABG was cross-validated in the SYNTAX trial (n=1,800) and externally validated in the CREDO-Kyoto (Coronary REvascularization Demonstrating Outcome Study in Kyoto) registry (n=7,362), and then compared with the original SYNTAX score II 2020 (SSII-2020). The hybrid gradient boosting model performed best for predicting 5-year all-cause death with C-indexes of 0.78 (95%CI: 0.75-0.81) in cross-validation and 0.77 (95%CI: 0.76-0.79) in external validation. The ML models discriminated 5-year mortality better than the SSII-2020 in the external validation cohort and identified heterogeneity in the treatment benefit of CABG vs PCI. An ML-based approach for identifying individuals who benefit from CABG or PCI is feasible and effective. Implementation of this model in health care systems-trained to collect large numbers of parameters-may harmonize decision making globally. (Synergy Between PCI With TAXUS and Cardiac Surgery: SYNTAX Extended Survival [SYNTAXES]; NCT03417050; SYNTAX Study: TAXUS Drug-Eluting Stent Versus Coronary Artery Bypass Surgery for the Treatment of Narrowed Arteries; NCT00114972).

Predicted and Observed Mortality at 10Years in Patients With Bifurcation Lesions intheSYNTAX Trial.

Percutaneous coronary intervention (PCI) of bifurcation lesions is associated with higher rates of adverse events, and currently it is unclear whether PCI or coronary artery bypass grafting (CABG) is the safer treatment for these patients at very long-term follow-up. The aim of this study was to investigate the impact of bifurcation lesions on individual predicted and observed all-cause 10-year mortality in the SYNTAX (Synergy Between PCI With Taxus and Cardiac Surgery) trial. In the SYNTAXES (SYNTAX Extended Survival) study, 10-year observed and individual predicted mortality derived from the SYNTAX score 2020 (SS-2020) was compared between patients with≥1 bifurcation (n=1,300) and those with no bifurcations (n=487). Among patients treated with PCI, patients with >1 bifurcation lesion compared with those without bifurcation lesions had a significantly higher risk for all-cause death (19.8% vs 30.1%; HR: 1.55; 95%CI: 1.12-2.14; P=0.007), whereas following CABG, mortality was similar in patients with and those without bifurcation lesions (23.3% vs 23.0%; HR: 0.81; 95%CI: 0.59-1.12; P=0.207; Pinteraction=0.006). In PCI patients, a 2-stent vs a 1-stent technique was associated with higher mortality (33.3% vs 25.9%; HR: 1.51; 95%CI: 1.06-2.14; P=0.021). According to the SS-2020, among those with≥1 bifurcation, there was equipoise for all-cause mortality between PCI and CABG in 2 quartiles of the population, whereas CABG was superior to PCI in the 2 remaining quartiles. Bifurcation lesions require special attention from the heart team, considering the higher 10-year all-cause mortality associated with PCI. Careful evaluation of bifurcation lesion complexity and calculation of individualized 10-year prognosis using the SS-2020 may therefore be helpful in decision making. (Synergy Between PCI With TAXUS and Cardiac Surgery: SYNTAX Extended Survival [SYNTAXES], NCT03417050; Taxus Drug-Eluting StentVersus Coronary Artery Bypass Surgery for the Treatment of Narrowed Arteries [SYNTAX], NCT00114972).

10-Year All-Cause Mortality Following Percutaneous or Surgical Revascularization inPatientsWithHeavyCalcification.

The aim of this study was to assess 10-year all-cause mortality in patients with heavily calcified lesions (HCLs) undergoing percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG). Limited data are available on very long term outcomes in patients with HCLs according to the mode of revascularization. This substudy of the SYNTAXES (Synergy Between PCI With Taxus and Cardiac Surgery Extended Survival) study assessed 10-year all-cause mortality according to the presence of HCLs within lesions with >50% diameter stenosis and identified during the calculation of the anatomical SYNTAX (Synergy Between PCI With Taxus and Cardiac Surgery) score among 1,800 patients with the 3-vessel disease and/or left main disease randomized to PCI or CABG in the SYNTAX trial. Patients with HCLs were further stratified according to disease type (3-vessel disease or left main disease) and assigned treatment (PCI or CABG). The 532 patients with≥1 HCL had a higher crude mortality rate at 10 years than those without (36.4% vs 22.3%; HR: 1.79; 95% CI: 1.49-2.16; P< 0.001). After adjustment, an HCL remained an independent predictor of 10-year mortality (HR: 1.36; 95%CI: 1.09-1.69; P=0.006). There was a significant interaction in mortality between treatment effect (PCI and CABG) and the presence or absence of HCLs (Pinteraction=0.005). In patients without HCLs, mortality was significantly higher after PCI than after CABG (26.0% vs 18.8%; HR: 1.44; 95%CI: 0.97-1.41; P=0.003), whereas in those with HCLs, there was no significant difference (34.0% vs 39.0%; HR: 0.85; 95%CI: 0.64-1.13; P=0.264). At 10 years, the presence of an HCL was an independent predictor of mortality, with a similar prognosis following PCI or CABG. Whether HCLs require special consideration when deciding the mode of revascularization beyond their current contribution to the anatomical SYNTAX score deserves further evaluation. (Synergy Between PCI With TAXUS and Cardiac Surgery: SYNTAX Extended Survival [SYNTAXES], NCT03417050; SYNTAX Study: TAXUS Drug-Eluting Stent Versus Coronary Artery Bypass Surgery for the Treatment of Narrowed Arteries [SYNTAX], NCT00114972).

Impact of Optimal Medical Therapy on 10-Year Mortality After Coronary Revascularization

BackgroundThe benefit of optimal medical therapy (OMT) on 5-year outcomes in patients with 3-vessel disease and/or left main disease after percutaneous coronary intervention or coronary artery bypass grafting (CABG) was demonstrated in the randomized SYNTAX (Synergy Between PCI With Taxus and Cardiac Surgery) trial. ObjectivesThe objective of this analysis is to assess the impact of the status of OMT at 5 years on 10-year mortality after percutaneous coronary intervention or CABG. MethodsThis is a subanalysis of the SYNTAXES (Synergy Between PCI With Taxus and Cardiac Surgery Extended Survival) study, which evaluated for up to 10 years the vital status of patients who were originally enrolled in the SYNTAX trial. OMT was defined as the combination of 4 types of medications: at least 1 antiplatelet drug, statin, angiotensin-converting enzyme inhibitor/angiotensin receptor blocker, and beta-blocker. After stratifying participants by the number of individual OMT agents at 5 years and randomized treatment, a landmark analysis was conducted to assess the association between treatment response and 10-year mortality. ResultsIn 1,472 patients, patients on OMT at 5 years had a significantly lower mortality at 10 years compared with those on ≤2 types of medications (13.1% vs 19.9%; adjusted HR: 0.470; 95% CI: 0.292-0.757; P = 0.002) but had a mortality similar to those on 3 types of medications. Furthermore, patients undergoing CABG with the individual OMT agents, antiplatelet drug and statin, at 5 years had lower 10-year mortality than those without. ConclusionsIn patients with 3-vessel and/or left main disease undergoing percutaneous coronary intervention or CABG, medication status at 5 years had a significant impact on 10-year mortality. Patients on OMT with guideline-recommended pharmacologic therapy at 5 years had a survival benefit. (Synergy Between PCI With Taxus and Cardiac Surgery: SYNTAX Extended Survival [SYNTAXES]; NCT03417050; Taxus Drug-Eluting Stent Versus Coronary Artery Bypass Surgery for the Treatment of Narrowed Arteries [SYNTAX]; NCT00114972)

10-Year Follow-Up After Revascularization in Elderly Patients With Complex Coronary Artery Disease

BackgroundThe optimal revascularization strategy for the elderly with complex coronary artery disease remains unclear. ObjectivesThe goal of this study was to investigate 10-year all-cause mortality, life expectancy, 5-year major adverse cardiac or cerebrovascular events (MACCE), and 5-year quality of life (QOL) after percutaneous coronary intervention (PCI) or coronary artery bypass graft (CABG) in elderly individuals (>70 years old) with 3-vessel disease (3VD) and/or left main disease (LMD). MethodsIn the present pre-specified analysis on age of the SYNTAX Extended Survival study, 10-year all-cause death and 5-year MACCE were compared with Kaplan-Meier estimates and Cox proportional hazards models among elderly or nonelderly patients. Life expectancy was estimated by restricted mean survival time within 10 years, and QOL status according to the Seattle Angina Questionnaire up to 5 years was assessed by linear mixed-effects models. ResultsAmong 1,800 randomized patients, 575 patients (31.9%) were elderly. Ten-year mortality did not differ significantly between PCI and CABG in elderly (44.1% vs. 41.1%; hazard ratio [HR]: 1.08; 95% confidence interval [CI]: 0.84 to 1.40) and nonelderly patients (21.1% vs. 16.6%; HR: 1.30; 95% CI: 1.00 to 1.69; pinteraction = 0.332). Among elderly patients, 5-year MACCE was comparable between PCI and CABG (39.4% vs. 35.1%; HR: 1.18; 95% CI: 0.90 to 1.56), whereas it was significantly higher in PCI over CABG among nonelderly patients (36.3% vs. 23.0%; HR: 1.69; 95% CI: 1.36 to 2.10; pinteraction = 0.043). There were no significant difference in life expectancy (mean difference: 0.2 years in favor of CABG; 95% CI: −0.4 to 0.7) and 5-year QOL status between PCI and CABG among elderly patients. ConclusionsElderly patients with 3VD and/or LMD had comparable 10-year all-cause death, life expectancy, 5-year MACCE, and 5-year QOL status irrespective of revascularization mode. (Synergy Between PCI With TAXUS and Cardiac Surgery: SYNTAX Extended Survival [SYNTAXES]; NCT03417050) (SYNTAX Study: TAXUS Drug-Eluting Stent Versus Coronary Artery Bypass Surgery for the Treatment of Narrowed Arteries [SYNTAX]; NCT00114972)

Mortality 10 Years After Percutaneous or Surgical Revascularization in Patients With Total Coronary Artery Occlusions

BackgroundThe long-term clinical benefit after percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG) in patients with total occlusions (TOs) and complex coronary artery disease has not yet been clarified. ObjectivesThe objective of this analysis was to assess 10-year all-cause mortality in patients with TOs undergoing PCI or CABG. MethodsThis is a subanalysis of patients with at least 1 TO in the SYNTAXES (Synergy Between PCI With Taxus and Cardiac Surgery Extended Survival) study, which investigated 10-year all-cause mortality in the SYNTAX (Synergy Between PCI With Taxus and Cardiac Surgery) trial, beyond its original 5-year follow-up. Patients with TOs were further stratified according to the status of TO recanalization or revascularization. ResultsOf 1,800 randomized patients to the PCI or CABG arm, 460 patients had at least 1 lesion of TO. In patients with TOs, the status of TO recanalization or revascularization was not associated with 10-year all-cause mortality, irrespective of the assigned treatment (PCI arm: 29.9% vs. 29.4%; adjusted hazard ratio [HR]: 0.992; 95% confidence interval [CI]: 0.474 to 2.075; p = 0.982; and CABG arm: 28.0% vs. 21.4%; adjusted HR: 0.656; 95% CI: 0.281 to 1.533; p = 0.330). When TOs existed in left main and/or left anterior descending artery, the status of TO recanalization or revascularization did not have an impact on the mortality (34.5% vs. 26.9%; adjusted HR: 0.896; 95% CI: 0.314 to 2.555; p = 0.837). ConclusionsAt 10-year follow-up, the status of TO recanalization or revascularization did not affect mortality, irrespective of the assigned treatment and location of TOs. The present study might support contemporary practice among high-volume chronic TO-PCI centers where recanalization is primarily offered to patients for the management of angina refractory to medical therapy when myocardial viability is confirmed. (Synergy Between PCI With TAXUS and Cardiac Surgery: SYNTAX Extended Survival [SYNTAXES]; NCT03417050; SYNTAX Study: TAXUS Drug-Eluting Stent Versus Coronary Artery Bypass Surgery for the Treatment of Narrowed Arteries [SYNTAX]; NCT00114972)

Fallacies and Possible Remedies of the SYNTAX Score.

Quite a few studies have revealed the clinical values regarding the outcome predictions in the cohort of the Synergy between Percutaneous Coronary Intervention with Taxus and Cardiac Surgery (SYNTAX) trial and decision-making with the SYNTAX score. The Evaluation of Xience Everolimus-Eluting Stent Versus Coronary Artery Bypass Surgery for Effectiveness of Left-Main Revascularization (EXCEL) and Nordic-Baltic-British left main revascularization (NOBLE) studies are the largest international randomized studies so far, comparing percutaneous coronary intervention (PCI) and coronary artery bypass graft (CABG) in the treatment of left main coronary artery disease. Unfortunately, both studies failed to validate the value of the SYNTAX score in the selection of revascularization strategies for patients with coronary artery diseases (CAD).. This scenario prompted us to reconsider the inherent fallacies of the SYNTAX score in its derivation. We pointed out eight fallacies for the SYNTAX score in this paper. A recently developed Coronary Artery Tree description and Lesion EvaluaTion (CatLet) score, available at http://www.catletscore.com, a novel angiographic scoring system, could be the remedies for the SYNTAX score.

Percutaneous Coronary Intervention With Drug Eluting Stents Versus Coronary Artery Bypass Graft Surgery in Patients With Advanced Chronic Kidney Disease: A Systematic Review and Meta-Analysis

Το perform a systematic review and meta-analysis of the available literature comparing safety and efficacy outcomes between percutaneous coronary intervention (PCI) with drug-eluting stents (DES) and coronary artery bypass grafting (CABG) in patients with chronic kidney disease (CKD). Eligible studies included patients with eGFR < 60 mL/min/1.73 m2 that underwent revascularization. Subgroup analyses according to DES generation and dialysis status were performed. A total of 7157 and 8156 patients were included in the CABG and PCI arms respectively across 16 studies eligible studies. Weighted mean age was 68.6 and 63.8 years for the CABG and PCI arms, respectively. Mean follow-up time was 3.2 and 2.9 years respectively. Compared to CABG, PCI was associated with increased risk for all-cause mortality (hazard ratio [HR]: 1.28, 95% confidence interval [CI]: 1.13, 1.46; P < 0.01), cardiac mortality (HR: 1.59, 95% CI: 1.13, 2.23; P = 0.01), myocardial infarction (MI) (HR: 1.89, 95% CI: 1.43, 2.49; P < 0.01), and repeat revascularization (HR: 2.97, 95% CI: 2.20, 3.97; P < 0.01). Risk for stroke was lower (HR: 0.64, 95% CI: 0.50, 0,81; P < 0.01) in the PCI group. These results were unchanged when 1st or 2nd DES were used. A subgroup analysis showed no difference in all-cause mortality for DES PCI vs CABG in dialysis patients (HR: 1.11, 95% CI: 0.71, 1.73; P = 0.65). In patients with CKD, PCI is associated with higher risk of mortality, MI, and repeat revascularization compared with CABG and regardless of DES generation. Risk of stroke is higher with CABG. Type of revascularization had no impact on survival of dialysis patients.

TCT CONNECT-304 Meta-Analysis of Long-Term Outcomes in Patients With Diabetes Mellitus and Left Main Coronary Artery Disease Treated With Drug-Eluting Stent Versus Coronary Artery Bypass Grafting

TCT CONNECT-304 Meta-Analysis of Long-Term Outcomes in Patients With Diabetes Mellitus and Left Main Coronary Artery Disease Treated With Drug-Eluting Stent Versus Coronary Artery Bypass Grafting

Impact of Peri-Procedural Myocardial Infarction on Outcomes After Revascularization

BackgroundNumerous definitions for peri-procedural myocardial infarction (PMI) following percutaneous coronary intervention (PCI) and coronary bypass grafting (CABG) surgery exist. ObjectivesThe purpose of this study was to investigate the PMI rates according to various definitions, their clinically relevant association with all-cause mortality at 10 years, and their impact on composite endpoints at 5 years in the SYNTAXES (Synergy between PCI with Taxus and Cardiac Surgery Extended Survival) trial. MethodsPMI was classified as a myocardial infarction occurring within 48 h of the procedure according to definitions of the SYNTAX (TAXUS Drug-Eluting Stent Versus Coronary Artery Bypass Surgery for the Treatment of Narrowed Arteries), ISCHEMIA (International Study Of Comparative Health Effectiveness With Medical And Invasive Approaches), and EXCEL (Evaluation of XIENCE versus Coronary Artery Bypass Surgery for Effectiveness of Left Main Revascularization) trials; the Fourth Universal Definition of MI; and the Society for Cardiovascular Angiography and Interventions (SCAI). Of the 1,800 patients enrolled, 1,652 with creatine kinase and/or creatine kinase-myocardial band (CK-MB) post-procedure were included. The association between PMI and mortality was analyzed by Cox regression. ResultsPMI rates according to the SYNTAX and Fourth Universal Definition of MI, both of which required CK-MB elevation and electrocardiographic evidence of permanent myocardial damage, were 2.7% and 3.0%, respectively, in the PCI arm versus 2.4% and 2.1%, respectively, in the CABG arm. PMI rates according to the SCAI or EXCEL definition were higher in the PCI (5.7%) and CABG (16.5%) arms. PMIs according to the SYNTAX and Fourth Universal Definition of MI were more strongly associated with mortality than EXCEL and SCAI PMIs defined by isolated enzyme elevation when CK-MB was more than 10 times ULN. The impact of these “enzyme-driven events” on time-to-event curves and the composite endpoints was greater in the surgical cohort. PMIs after PCI were associated with 10-year mortality regardless of definition, whereas their impact on mortality after CABG was limited to 1 year. ConclusionsThe rates of PMI are highly dependent on their definition, which affects time-to-event curves, composite endpoints, and their lethal prognostic relevance. (Synergy Between PCI With TAXUS and Cardiac Surgery: SYNTAX Extended Survival [SYNTAXES]; NCT03417050; SYNTAX Study: TAXUS Drug-Eluting Stent Versus Coronary Artery Bypass Surgery for the Treatment of Narrowed Arteries [SYNTAX]; NCT00114972)

Sex Differences in All-Cause Mortality in the Decade Following Complex Coronary Revascularization

BackgroundThe poorer prognosis of coronary artery disease in females compared with males is related mainly to differences in baseline characteristics. In the SYNTAX (Synergy Between Percutaneous Coronary Intervention With Taxus and Cardiac Surgery) trial, the effect of treatment with percutaneous coronary intervention (PCI) versus coronary artery bypass grafting surgery (CABG) on mortality at 5 years differed significantly between females and males; however, the optimal revascularization beyond 5 years according to sex has not been evaluated. ObjectivesThe aim of this study was to investigate the impact of sex on mortality and sex-treatment interaction at 10 years. MethodsThe SYNTAXES (SYNTAX Extended Survival) study evaluated vital status up to 10 years in 1,800 patients with de novo 3-vessel and/or left main coronary artery disease randomized to treatment with PCI or CABG in the SYNTAX trial. All-cause death at 10 years was separately evaluated in female and male patients with complex coronary artery disease. ResultsOf 1,800 patients, 402 (22.3%) were female and 1,398 (77.7%) were males. Females had a higher 10-year mortality rate compared with males (32.8% vs. 24.7%; log-rank p = 0.002), but female sex was not an independent predictor of mortality (adjusted hazard ratio: 1.02; 95% confidence interval: 0.76 to 1.36). Mortality at 10 years tended to be lower after CABG than after PCI, with a similar treatment effect for female and male patients (adjusted hazard ratio for females: 0.90 [95% confidence interval: 0.54 to 1.51]; adjusted hazard ratio for males: 0.76 [95% confidence interval: 0.56 to 1.02]; p for interaction = 0.952). ConclusionsFemale sex was not an independent predictor of mortality at 10 years in patients with complex coronary artery disease. The interaction between sex and treatment with PCI or CABG that was observed at 5 years was no longer present at 10 years. (Synergy Between PCI With TAXUS and Cardiac Surgery: SYNTAX Extended Survival [SYNTAXES], NCT03417050; SYNTAX Study: TAXUS Drug-Eluting Stent Versus Coronary Artery Bypass Surgery for the Treatment of Narrowed Arteries [SYNTAX], NCT00114972)

Lo mejor del Congreso Virtual ACC/WCC 2020

The SARS-CoV-2 pandemic has been a global challenge. In times of difficulty such as those that have recently arisen, research is even more necessary to advance in the diagnosis and treatment of different pathologies. Using the extensive development of the media, this year the American Congress of Cardiology was held from March 28 to 30 in a virtual format, allowing professionals from around the world to access multiple scientific activities with the same level of excellence as in face-to-face sessions.We will make a brief summary of some of the main scientific papers presented: Tailored Antiplatelet Initiation to Lessen Outcomes Due to Decreased Clopidogrel Response after Percutaneous Coronary Intervention: TAILOR–PCI. Rivaroxaban in Peripheral Artery Disease after Revascularization: VOYAGER PAD trial Vericiguat in Patients with Heart Failure and Reduced Ejection Fraction: VICTORIA Study Group. The Evolut Low Risk Bicuspid Study. PARTNER 3. Two-year clinical and echocardiographic outcomes. Ticagrelor with and without Aspirin in Acute Coronary Syndrome After PCI: the TICO Trial. Apixaban for the Treatment of Venous Thromboembolism Associated with Cancer: Caravaggio trial. Ten-year Outcomes After Drug-eluting Stents Versus Coronary Artery Bypass Grafting for Left Main Coronary Disease: Extended Follow Up of the PRECOMBAT Trial. Anticoagulation with or without Clopidogrel after Transcatheter Aortic-Valve Implantation: POPular TAVI.

TCT-391 10-Year Clinical Outcomes After Stents Versus Coronary Artery Bypass Grafting for Left Main Coronary Artery Disease According to Lesion Location: Results From the MAIN-COMPARE Registry

TCT-391 10-Year Clinical Outcomes After Stents Versus Coronary Artery Bypass Grafting for Left Main Coronary Artery Disease According to Lesion Location: Results From the MAIN-COMPARE Registry

Insulin resistance and the severity of coronary artery disease based on obesity status in stable-angina patients: A cross-sectional analysis

The evaluation of coronary artery disease (CAD) concerning the metabolic status and body mass index (BMI) is poorly studied. This study was designed to observe the relationship between insulin resistance (IR) and the severity of CAD on the basis of the metabolic and phenotypic status in stable-angina patients. A cross-sectional study was conducted on 532 patients with stable angina and coronary angiogram was done to diagnose the CAD for all. Determination of metabolic obesity was done using the National Cholesterol Education Program-Adult Treatment Panel III criteria. Phenotypic obesity was defined as BMI ≥ 25 kg/m2. Homeostasis model assessment IR in correlation with the severity of CAD was measured using SYNTAX (TAXUS Drug-Eluting Stent Versus Coronary Artery Bypass Surgery for the Treatment of Narrowed Arteries) Score. The average age of the patients was 57.58 ± 10.40 years, and 69.4% were males. Out of 532 subjects, 51.3% were hypertensive, 14.5% were smokers, 29.1% consumed alcohol, 49.3% were metabolically obese, and 50% were phenotypically obese. Increase in IR increased the risk of severity of CAD in metabolically obese subjects (OR = 2.51, p = 0.048). In the phenotypically obese group, the relationship between IR and the severity of CAD was not statistically significant (OR = −2.19, p = 0.08). The study concludes that the increased IR increases the risk of severity of CAD in metabolically obese subjects.

Drug-Eluting Stent Versus Coronary Artery Bypass Grafting for Diabetic Patients With Multivessel and/or Left Main Coronary Artery Disease: A Meta-Analysis.

With the development of stent design and surgical techniques, the relative benefit of percutaneous coronary intervention (PCI) versus coronary artery bypass grafting (CABG) in patients with diabetes and complex coronary artery disease are highly debated. This meta-analysis was conducted to compare the outcomes of drug-eluting stent (DES) implantation and CABG in these cohorts. A comprehensive search of PubMed, Embase, and Cochrane Library up to January 4, 2018, was performed. Only randomized controlled trials (RCTs), subgroup analysis from RCTs, or adjusted observational studies were eligible. Five RCTs and 13 adjusted observational studies involving 17 532 patients were included. Overall, PCI with DES was significantly associated with higher risk of all-cause mortality (hazard ratio [HR]: 1.16, 95% confidence interval [CI]: 1.05-1.29), myocardial infarction (MI; HR: 1.69, 95% CI: 1.43-2.00), and repeat revascularization (HR: 3.77, 95% CI: 2.76-5.16) compared with CABG. Nevertheless, the risk of stroke was significantly lower in the DES group (HR: 0.67, 95% CI: 0.54-0.83). The incidence of the composite end point of death, MI, or stroke was comparable between the 2 groups (HR: 0.99, 95% CI: 0.84-1.17). Despite the higher risk of stroke, CABG was better than PCI with DES for diabetic patients with multivessel and/or left main coronary artery disease.

A Meta-Analysis Comparing Percutaneous Coronary Intervention With Drug-Eluting Stents Versus Coronary Artery Bypass Grafting in Unprotected Left Main Disease

Coronary artery bypass grafting (CABG) is the preferred revascularization strategy for unprotected left main disease (UPLMD). Multiple small-scale trials and registry data showed that percutaneous coronary intervention (PCI) with drug-eluting stents (DES) is a noninferior strategy with a Class IIa American College of Cardiology/American Heart Association recommendation in patients with high surgical risk and favorable anatomy. However, 2 recent large-scale randomized trials showed conflicting evidence. We conducted a meta-analysis of the existing data to compare outcomes of PCI with DES versus CABG for UPLMD. Four randomized and 8 nonrandomized trials involving 10,284 patients were included. Primary end point was composite of death, stroke, or myocardial infarction (MI) at 3 years or longer. Secondary end points were MACCE (Major Adverse Cardiac and Cerebrovascular Events) and its individual components (death, stroke, MI, or repeat revascularization). Mantel-Haenszel random effects model was used to calculate combined odds ratio for outcomes. A separate analysis of randomized data was also performed. There was no significant difference in primary composite outcome between PCI and CABG. However, MACCE was significantly higher in PCI, primarily driven by significantly high repeat revascularization. A subgroup analysis stratified by Synergy between PCI with Taxus and Cardiac Surgery (SYNTAX) score showed that MACCE and repeat revascularization were not significantly different between PCI and CABG in low to intermediate SYNTAX score (<33), whereas they were significantly higher in PCI with higher SYNTAX score. Thus, although CABG remains the preferred method of treatment in UPLMD, PCI with DES can be considered as a reasonable alternative in patients with favorable anatomy and high surgical risk.

Drug-eluting stents Versus Coronary Artery Bypass Grafting in Multivessel Disease and Left Main Obstruction: Meta-analysis of Randomized Clinical Trials

Background: The choice between percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG) remains controversial. Objective: To conduct a meta-analysis of randomized studies comparing drug-eluting stents (DES) and CABG in multivessel disease or obstruction of the left main coronary artery. Method: Electronic databases were searched systematically to evaluate results of randomized trials comparing PCI with DES versus CABG in multivessel disease and obstruction of the left main coronary artery. Ten studies were identified. Results: In the aggregated results (n = 9268), mortality at 30 days and incidence of stroke favored PCI (0.8% versus 1.5%, p = 0.005; 0.4% versus 1.5%, p < 0.0001, respectively). There was no difference in mortality at 1 year (3.4% versus 3.5%, p = 0.50). The late mortality favored CABG (10.1% versus 8.5%, p = 0.01). In patients with diabetes derived from four studies (n = 3830), late mortality favored CABG (12.5% versus 9.7%, p < 0.0001). In six studies of left main coronary artery obstruction (n = 4700), the incidence of stroke favored PCI (0.3% versus 1.5%, p < 0.001) and there was no difference in mortality at 30 days (0.8% versus 1.3%, p = 0.15), mortality at 1 year, or late mortality (8.1% versus 8.1%). The subgroups with high SYNTAX score and diabetes were those influencing most strongly and adversely the PCI results. Conclusion: When compared with PCI, CABG was superior in regards to late mortality and inferior in regards to 30-day mortality and incidence of stroke. Diabetes and SYNTAX score strongly impacted the results.

Drug-Eluting Stents Versus Coronary Artery Bypass Grafts for Left Main Coronary Disease: A Meta-Analysis and Review of Randomised Controlled Trials

Revascularisation of left main coronary artery (LMCA) disease can be potentially managed with percutaneous coronary intervention (PCI) or coronary artery bypass graft surgery (CABG). Recent randomised controlled trial (RCT) data have added to the literature on this subject and this meta-analysis aims to assess the state of the data to assist in guiding patient treatment decisions. A systematic literature search of Cochrane Library, EMBASE, OVID, and PubMed Medline was performed. Randomised controlled trials of patients with LMCA disease undergoing PCI with drug eluting stents or CABG were included. Clinical outcomes and adverse events were assessed and analysed. Four suitable RCTs of adequate quality and follow-up were identified. The incidence of major adverse cardiac and cerebrovascular events (MACCE) at 3 to 5 years of follow-up was significantly increased with PCI compared to CABG (23.3% vs 18.2%, OR 1.37; 95% CI: 1.18-1.58; p=<0.0001; I2=0%) and was largely driven by more repeat revascularisation procedures among patients treated with PCI. There was no statistically significant difference in rates of mortality, myocardial infarction or stroke (either individually or when these outcomes were combined as a composite endpoint). Coronary artery bypass grafting and PCI both represent reasonable treatment modalities for LMCA disease in appropriately selected patients. However, where CABG is feasible it offers superior long-term freedom from repeat revascularisation. Longer-term follow-up is required to further clarify the durability of mortality outcomes, especially in patients treated with PCI.

Percutaneous Coronary Intervention of Left Main Disease: Pre- and Post-EXCEL (Evaluation of XIENCE Everolimus Eluting Stent Versus Coronary Artery Bypass Surgery for Effectiveness of Left Main Revascularization) and NOBLE (Nordic-Baltic-British Left Main Revascularization Study) Era.

For nearly half a century, coronary artery bypass grafting has been the standard treatment for patients with obstructive left main coronary artery (LMCA) disease. However, there has been considerable evolution in the field of percutaneous coronary intervention, and especially, percutaneous coronary intervention for LMCA disease has been rapidly expanded with adoption of drug-eluting stents. Some, but not all randomized trials, have shown that percutaneous coronary intervention with drug-eluting stents might be a suitable alternative for selected patients with LMCA disease instead of bypass surgery. However, none of previous trials involving early-generation drug-eluting stents was sufficiently powered and comparative trials using contemporary drug-eluting stents were limited. Recently, primary results of 2 new trials of EXCEL (Evaluation of XIENCE Everolimus Eluting Stent Versus Coronary Artery Bypass Surgery for Effectiveness of Left Main Revascularization) and NOBLE (Nordic-Baltic-British Left Main Revascularization Study) were reported. However, these trials showed conflicting results, which might pose uncertainty on the optimal revascularization strategy for LMCA disease. In this article, with the incorporation of a key review on evolution of LMCA treatment, we summarize the similarity or disparity of the EXCEL and NOBLE trials, focus on how they relate to previous trials in the field, and finally speculate on how the treatment strategy may be changed or recommended for LMCA treatment.