Terms Of Major Adverse Cardiovascular Events Research Articles

A comprehensive guide on the optimal timing of PCI in the setting of acute coronary syndrome: An updated meta-analysis

BackgroundInvasive revascularization is recommended for cohorts of patients with ST-elevation myocardial infarction (STEMI) and non-ST-elevation acute coronary syndrome (NSTE-ACS). However, the optimal timing of invasive revascularization is still controversial and no defined consensus is established. We aim to give a comprehensive appraisal on the optimal timing of invasive strategy in the heterogenous population of ACS. MethodsRelevant studies were assessed through PubMed, Scopus, Web of science, and Cochrane Library from inception until April 2023. Major adverse cardiovascular events (MACE) and all-cause mortality were our primary outcomes of interest, other secondary outcomes were cardiac death, TVR, MI, repeat revascularization, recurrent ischemia, and major bleeding. The data was pooled as odds ratio (OR) with its 95% confidence interval (CI) in a random effect model using STATA 17 MP. ResultsA total of 26 studies comprising 21,443 patients were included in the analysis. Early intervention was favor to decrease all-cause mortality (OR = 0.79, 95% CI: 0.64 to 0.98, p = 0.03), when compared to delayed intervention. Subgroup analysis showed that early intervention was significantly associated with all-cause mortality reduction in only NSTE-ACS (OR = 0.83, 95% CI [0.7 to 0.99], p = 0.04). However, there was no significant difference between early and delayed intervention in terms of MACE, cardiac death, TVR, MI, repeat revascularization, recurrent ischemia, and major bleeding. ConclusionAn early intervention was associated with lower mortality rates compared to delayed intervention in NSTE-ACS with no significant difference in other clinical outcomes.PROSPERO registration: CRD42023415574.

Abstract 17686: Safety and Efficacy of Drug-Eluting Stents for Patients at High Risk of Bleedings: A Network Meta-Analysis

Introduction: Among different coronary stents implanted in High Bleeding Risk (HBR) patients with an indication for short antiplatelet therapy, no comparisons in terms of efficacy have been provided. Methods: A Network Meta Analysis was performed including all Randomized Controlled Trials comparing different coronary stents evaluated in HBR patients. Major Adverse Cardiovascular Events (MACEs) as defined by each included trial were the primary end point, whereas TLR (target lesion revascularization), TVR (target vessel revascularization), stent thrombosis and total and major (BARC3-5) bleedings were the secondary ones. Results: A total of 4 studies (ONYX ONE, LEADERS FREE, SENIOR and HBR in BIO-RESORT) including 6637 patients were analyzed with different kind of stents and DAPT length (1 or 6 months) on 12 months follow-up. About one third of these patients were defined HBR due to indication for oral anticoagulation. All Drug Eluting Stents (DESs) reduced risk of MACE compared to Bare Metal Stents (BMSs) when followed by a 1-month DAPT. At SUCRA analysis, Orsiro was the device with the highest probability of performing best. Rates of TLR and TVR were significantly lower when using Resolute Onyx, Synergy and BioFreedom stents in comparison to BMS when followed by 1-month DAPT, with Synergy ranking best. Synergy also showed a significantly lower number of stent thrombosis compared to BMS (RR 0.28, 95%CI 0.06-0.93), while Orsiro and Resolute Integrity showed the highest probability of performing best. Conclusion: In HBRs patients, all DESs were superior to BMSs in terms of efficacy and safety. Among DESs, Orsiro was the one with the highest ranking in terms of MACE, mainly driven by a reduced incidence of repeated revascularization and stent thrombosis

Comparison of Outcomes Between Angiotensin-Converting Enzyme Inhibitors and Angiotensin II Receptor Blockers in Patients With Myocardial Infarction: A Meta-Analysis.

Patients with acute myocardial infarction (AMI) are usually treated with angiotensin-converting enzyme inhibitors (ACEi) or angiotensin II receptor blockers (ARB). The aim of this meta-analysis is to compare outcomes between ACEi and ARB in patients with myocardial infarction (MI).This meta-analysis was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 guidelines.Three major online databases, including PubMed, EMBASE, and the Cochrane Library, were thoroughly searched to find studies comparing ACEi and ARB in patients with MI from January 1, 2000, onwards, without language or publication restrictions.Outcomes assessed in this meta-analysis included major adverse cardiovascular events (MACE), all-cause mortality, cardiovascular mortality, stroke, and hospitalization due to heart failure. A total of 16 studies were included in this meta-analysis. Pooled estimates showed no significant differences between the two groups in terms of MACE (risk ratio (RR): 1.03, 95% confidence interval (CI): 0.88-1.20), all-cause mortality(RR: 1.03, 95% CI: 0.88-1.20), cardiovascular mortality(RR: 1.00, 95% CI: 0.89-1.12), stroke(RR: 1.03, 95% CI: 0.80-1.32), andhospitalization due to heart failure(RR: 0.99, 95% CI: 0.90-1.09).These results suggest that ACEi and ARB have similar impacts on clinical outcomes across a broad spectrum of MI patients, reinforcing their roles in post-MI treatment.

Adding parenteral anticoagulation in STEMI undergoing PCI: safety and efficacy?

Abstract Funding Acknowledgements Type of funding sources: None. Introduction Antithrombotic therapy is the cornerstone treatment for acute coronary syndromes. Often, parenteral anticoagulation (AC) is added to the dual antiplatelet treatment, till primary percutaneous coronary intervention (PCI). This strategy is recommended by latest guidelines, due to large experience, however, there has been no placebo-controlled trial evaluating the efficacy or safety of AC in primary PCI. Purpose This study aims to evaluate the efficacy and safety of treatment with parenteral AC, either with UFH or with low molecular weight heparin (LMWH), in ST segment elevation myocardial infarction (STEMI), undergoing PCI. Methods Retrospective, multicenter, cohort of 1052 STEMI patients, admitted to primary PCI was divided in two groups: one undergoing parenteral AC and one with no AC. We did a sub analyze comparing the group treated with UFH and LMWH, against placebo. The primary efficacy endpoints were in-hospital and one year follow-up mortality, major adverse cardiovascular events (MACE) during hospitalization (re-infarction, mechanical complication, sudden cardiac death averted, ventricular arrhythmia, heart failure, stroke, and cardiogenic shock) and glycoprotein IIaIIIb inhibitor bailout strategy (GPIIaIIIb). The safety endpoints were TIMI major bleeding and decrease of hemoglobin (Hb) value greater than 3g/dL. Results Of the total of 1052 patients: 564 (54%) were treated with parenteral anticoagulation and 488 were not. In the anticoagulation sample, 207 patients were treated with UFH (37%), and 357 patients were treated with LMWH (63%). There were no statistically significant differences in both groups, in terms of age and sex distribution, with a 18-26% of women and mean age of 62,8-66,2±0,9 years old. AC, and LMWH, had a statistically significant association with lower in-hospital mortality (p<0,01), with odds ratio (OR) 0,3 and 0,28 respectively. UFH did not have a statistically significant association with lower mortality (p=0,8). In terms of follow-up mortality, there was no statistically significant association in either group. In terms of MACE and GPIIaIIIb, AC, LMWH and UFH had a statistically significant association with lower MACE and GPIIaIIIB (p<0,01), with a OR 0,9, OR 0,56 and OR 0,77 respectively, on MACE, and with OR 0,1, OR 0,3 and OR 0,2, on GPIIaIIIB. Regarding safety, neither AC, nor LMWH or UFH, had a statistically significant association with TIMI major bleeding (p=0,24, p=0,2, and p=0,8). LMWH had a statistically significant association with Hb value decrease greater than 3g/dL (p=0,03 RR 6%), that was not verified in AC or UFH samples (p=0,1), against placebo. Conclusion Adding AC, in STEMI patients admitted to primary PCI, to the antithrombotic therapy strategy is associated with lower in-hospital mortality, MACE and GPIIaIIIB bailout strategy, without increasing rates of TIMI major bleeding or Hb value decrease greater than 3g/dL.

Management of Restenosis after Stenting in Left Main Coronary Artery Disease.

The optimal alternative treatment strategy to coronary artery bypass graft surgery (CABG) for in-stent restenosis (ISR) in left main (LM) coronary artery disease remains uncertain. We retrospectively screened all intervention reports from an intervention database and extracted those mentioning an LM stent. We then manually confirmed reports involving LM ISR and divided them into two groups, those in which the patient received a new drug-eluting stent (new-DES) strategy, and those in which the patient received a drug-coated balloon (DCB) only. A composite endpoint of major adverse cardiovascular events (MACEs) and each individual endpoint were compared. We also performed a brief analysis of similar designed studies. Between the new-DES (n = 40) and DCB-only (n = 22) groups, during median respective follow-up times of 581.5 and 642.5 days, no significant statistical differences were detected in MACEs (50.0% vs. 50.0%, p = 0.974), cardiovascular death (27.5% vs. 13.6%, p = 0.214), nonfatal myocardial infarction (30.0% vs. 31.8%, p = 0.835), or target lesion revascularization (35.0% vs. 45.5%, p = 0.542). We analyzed four similar studies and found comparable MACE findings (odds ratio: 0.85, 95% CI: 0.44-1.67). Our findings support both DCB angioplasty and repeat DES implantation for LMISR lesions in patients who were clinically judged to be unsuitable for CABG; the treatments achieved comparable clinical results in terms of MACEs in the medium term.

Clinical outcomes in patients undergoing complex, high-risk percutaneous coronary intervention and haemodynamic support with intra-aortic balloon versus Impella pump: Real-life single-centre preliminary results.

Patients and mechanical circulatory support assortment, as well as periprocedural and post-procedural clinical outcomes in complex high-risk percutaneous coronary interventions (PCIs) underpinned by percutaneous left ventricular assist devices (pLVAD) are the subject of debate. The study aimed to identify differences between patients qualified for complex high-risk PCIs with an intra-aortic balloon pump (IABP) or Impella pump support and to compare peri- and post-procedural clinical outcomes. The presented analysis is a single-center study, which comprised consecutive patients undergoing complex high-risk PCIs performed with the pLVAD, either IABP or Impella. Patients included in the current analysis were recruited between January 2018 and December 2021. There were 28 (56%) patients in the Impella group and 22 (44%) in the IABP group. The primary endpoints included overall mortality and major adverse cardiovascular events (MACE) such as all-cause mortality, myocardial infarction, revascularization, and cerebrovascular events. Patients from the IABP group were significantly older, had higher left ventricular ejection fraction (LVEF), and less frequent history of PCI, while the in-hospital risk of death assessed by EuroSCORE II remained similar in the Impella and IABP groups (median interquartile range [IQR] 2.8 [2-3.8] vs. 2.5 [1.8-5.2]; P = 0.73). Patients undergoing complex high-risk PCIs with pLVAD support presented similar results during the follow-up, assessed by log-rank estimates in terms of MACE (P = 0.41) and mortality rate (P = 0.65). The use of pLVAD devices in patients undergoing complex high-risk PCIs, with reduced left ventricular ejection fraction, is a promising treatment option for patients disqualified from surgery by cardiac surgeons.

Abbreviated dual antiplatelet therapy after PCI in patients at high bleeding risk: a collaborative meta-analysis of randomized trials

Abstract Aims The optimal duration of dual antiplatelet therapy (DAPT) after percutaneous coronary intervention (PCI) in patients at high bleeding risk (HBR) is still debated. We appraised an abbreviated compared with a more prolonged DAPT regimen in this setting by using the totality of existing evidence. Methods and results A systematic review and meta-analysis was performed to search randomized clinical trials comparing abbreviated (i.e., short [3 months] or very-short [1 month]) with standard (≥6 months) DAPT in HBR patients. Six trials with 8,409 patients were included. Major or clinically relevant non-major bleeding (MCRB) and major adverse cardiovascular events (MACE) were the co-primary safety and efficacy endpoints. MCRB was lower with abbreviated compared to standard DAPT (risk ratio [RR] 0.63, 95% CI 0.41–0.95; I2=74%). No difference in terms of MACE (RR 1.03, 95% CI 0.89–1.20; I2=0%) all-cause death, cardiovascular death, stent thrombosis or myocardial infarction were observed. Network meta-analysis showed short or very-short DAPT to have the highest probability to prevent bleeding in HBR patients. Conclusion Abbreviated DAPT reduced bleeding without apparent increase in ischemic events in HBR patients undergoing PCI. Three-month or one-month DAPT courses appeared similarly effective to optimize the trade-off for ischemia and bleeding in this population. Funding Acknowledgement Type of funding sources: None.

Impact of Side Branch Lesion Length on Clinical Outcome after Coronary Stenting Techniques in Patients with Coronary Artery Bifurcation Disease: A Meta-Analysis

Objective: The optimal percutaneous coronary intervention (PCI) technique for bifurcation lesions remains controversial, especially considering the variability of the side branch (SB). A provisional stenting technique is currently recommended in most cases. This meta-analysis aimed to compare outcomes of different bifurcation PCI strategies, clarifying their scope of application. Methods: Randomized controlled trials comparing PCI strategies for coronary bifurcation lesions were systematically retrieved from PubMed, Cochrane, Web of Science, and EBSCO literature databases without limitations on published date or language. Major adverse cardiovascular events (MACEs) were stipulated as main outcomes. Secondary outcomes of interest were all-cause mortality, cardiovascular mortality, target lesion revascularization (TLR), target vessel revascularization, myocardial infarction (MI), and stent thrombosis. Both pooled analysis and sub-group analysis were performed. Results: Twenty-three randomized controlled trials with 6380 participants were included. Eighteen studies compared the provisional strategy with 2-stent approaches. No significant difference in MACEs (relative risk (RR), 1.16; 95% confidence interval (CI), 0.90–1.48; I2 = 62%) was found between 1-stent and 2-stent techniques. However, when SB lesion length was used as the separation condition, the 2-stent strategy was associated with fewer MACEs (RR, 1.87; 95% CI, 1.46–2.41; I2 = 70%), TLRs (RR, 2.13; 95% CI, 1.50–3.02; I2 = 59%), and MIs (RR, 2.17; 95% CI, 1.19–3.95; I2 = 52%) than the provisional strategy in those where SB lesions measured >10 mm long. Conclusions: In the current work, there was no significant difference between 1-stent and 2-stent techniques in terms of MACEs or secondary outcomes. However, 2-stent approaches have clinical advantages over the provisional strategy in bifurcation when the SB lesion length is >10 mm due to fewer cases of TLR and MI.

Glycemic Control Status and Long-Term Clinical Outcomes in Diabetic Chronic Total Occlusion Patients: An Observational Study.

Background Whether good glycemic control can result in clinical benefits for diabetic chronic total occlusion (CTO) patients is still a matter of debate. Methods We studied 1029 diabetic CTO patients. Based on one-year glycosylated hemoglobin A (HbA1c) levels, we assigned the patients into 2 groups: HbA1c<7% group (n = 448) and HbA1c ≥ 7% group (n = 581). We further subdivided the patients into the successful CTO revascularization (CTO-SR) and nonsuccessful CTO revascularization (CTO-NSR) groups. Kaplan–Meier analysis and Cox regression before and after propensity score matching were used to compare major adverse cardiovascular events (MACE) and other endpoints. Results There were no significant differences between the groups in terms of most endpoints in the overall patients. After propensity score-matched analysis, patients with HbA1c < 7.0 tended to be superior in terms of MACE, which was mainly attributed to repeat revascularization but the other endpoints. Furthermore, the benefit of the HbA1c < 7 group was more prominent among patients with CTO-NSR in terms of MACE, repeat revascularization, and target vessel revascularization (TVR); and the improvement of the HbAc1 < 7 group was more prominent among patients without chronic heart failure (CHF) (P=0.027). Conclusions HbA1c < 7.0 was associated with a reduced incidence of MACE, which was mainly attributed to a reduction in repeat revascularization. Good glycemic control can improve diabetic CTO patients' clinical prognosis, especially in CTO-NSR patients.

The prognostic value of late gadolinium enhancement in heart diseases: an umbrella review of meta-analyses of observational studies.

Cardiac magnetic resonance imaging (CMR) has proven itself as an accurate and robust diagnostic approach and has been widely used in the detection of various heart diseases. An increasing number of studies focusing more on the prognostic aspect of LGE-CMR arose in recent years, contributing to the redundant systematic reviews and meta-analyses in this field. By providing a bird's eye view and performing scrupulous evidence rating, this umbrella review aims to help clinical practitioners and policy-makers interpret the results of the meta-analyses on the prognostic role of late gadolinium enhancement (LGE) in patients with heart diseases. An umbrella review of meta-analyses of observational studies. The 11 included systematic reviews comprise 33 meta-analyses covering 11 types of heart diseases, 19 different outcomes, 23,058 subjects, and 5393 events. Thirty-one of 33 meta-analyses were found supported by weak pieces of evidence and the remaining were deemed not suggestive. The meta-analysis with a p value of 9.21 × 10-15 and 991 events was updated by strictly re-conducting the meta-analysis by Becker et al. The updated meta-analysis on the prognostic role of LGE in subjects with non-ischemic dilated cardiomyopathy (DCM) in terms of major adverse cardiovascular events (MACE) included 1131 events and was rated as highly suggestive evidence. The prognostic role of LGE in DCM patients in terms of MACE is supported by highly suggestive evidence, which may facilitate the optimization of the timing of prophylactic implantable or wearable implantable cardioverter-defibrillators (ICD) considering the high risk of MACE and lower expectation of recovery. • Cardiac magnetic resonance imaging (CMR) has been widely used in the detection of various heart diseases. Numerous studies focusing on the prognostic aspect of LGE arose in recent years. • The meta-analysis on the prognostic role of LGE in dilated cardiomyopathy (DCM) patients in terms of major adverse cardiovascular events (MACE) by Becker et al was updated and was deemed to be supported by highly suggestive evidence. • The credibility of the meta-analysis supported by highly suggestive evidence may facilitate the optimization of the timing of prophylactic implantable or wearable implantable cardioverter defibrillators (ICD) considering the high risk of MACE and lower expectation of recovery.

Meta-Analysis Comparing Potent Oral P2Y12 Inhibitors versus Clopidogrel in Patients with Atrial Fibrillation Undergoing Percutaneous Coronary Intervention.

BackgroundIn patients with atrial fibrillation (AF) receiving percutaneous coronary intervention (PCI), current guidelines recommend against combining potent oral P2Y12 inhibitors (i.e. ticagrelor or prasugrel) with oral anticoagulant (OAC) therapy, but the evidence is limited.ObjectiveThe aim of this meta-analysis was to compare the efficacy and safety of potent oral P2Y12 inhibitors with clopidogrel in patients receiving OAC therapy for AF after a recent PCI.MethodsElectronic databases were searched for randomized controlled trials (RCT) reporting outcomes according to the P2Y12 inhibitor used. Major or clinically relevant non-major bleeding were the safety endpoints, while the efficacy outcomes were major adverse cardiovascular events (MACE). The potent oral P2Y12 inhibitors prasugrel and ticagrelor were compared with clopidogrel. A subgroup analysis was conducted to evaluate the differences between patients treated with dual antithrombotic therapy (DAT) versus triple antithrombotic therapy (TAT).ResultsFour RCTs that included 10,057 patients were included in this analysis. Potent oral P2Y12 inhibitors were associated with a significant increase in major or clinically relevant non-major bleeding compared with clopidogrel (risk ratio [RR] 1.30, 95% confidence interval [CI] 1.06–1.59, p = 0.01; number needed to harm 18, 95% CI 12–36). This finding was consistent regardless of the concomitant antithrombotic therapy (DAT vs. TAT; p = 0.69). The risk of MACE did not differ between potent oral P2Y12 inhibitors and clopidogrel (RR 1.02, 95% CI 0.57–1.82).ConclusionsIn patients receiving OAC therapy for AF after a recent PCI, potent oral P2Y12 inhibitors increase the risk of clinically relevant bleeding compared with clopidogrel, with no evident benefit in terms of MACE reduction.Electronic supplementary materialThe online version of this article (10.1007/s40256-020-00436-8) contains supplementary material, which is available to authorized users.

Safety and efficacy of anticoagulant monotherapy in atrial fibrillation and stable coronary artery disease: A systematic review and meta-analysis

BackgroundAdjunctive use of oral anticoagulant (OAC) and antiplatelet therapy (APT) in patients with stable coronary artery disease (CAD) and nonvalvular atrial fibrillation (AF) is a challenge of daily practice. MethodsA comprehensive literature search of databases was performed to identify studies comparing the safety and efficacy of OAC monotherapy and combined therapy (OAC plus single (S) APT). Events including major adverse cardiovascular events (MACE), all-cause mortality, stroke and major bleeding were analyzed. ResultsSeven articles comprising 11,070 subjects were identified. Combined therapy was associated with a significantly higher risk of major bleeding (pooled hazard ratio (HR) of 1.62, 95% CI 1.40–1.86, p=<0.0001) compared to the OAC monotherapy. There was no significant difference between the two comparison arms in terms of MACE (HR 1.14; 95% CI 0.97–1.34, p = 0.11), stroke (HR 1.05; 95% CI 0.77–1.43, p = 0.78) and all-cause mortality (HR 1.15; 95% CI 0.94–1.40, p = 0.16). Stratified analysis by inclusion of only patients with coronary stents attenuated the safety effect of monotherapy. Subgroup analysis based on the study design, type of OAC, major bleeding criteria and APT revealed findings consistent with the pooled HR. The combined therapy group had a 19% and 38% higher risk of MACE in studies with a history of MI (p = 0.03) and with the use of rivaroxaban (p = 0.02), respectively. ConclusionOAC monotherapy might have a lower incidence of major bleeding events with no higher overall risk of MACE, ischemic stroke and all-cause mortality compared to the combined therapy group.

Abstract TP125: Stent as a Treatment for Cranio-Cervical Artery Dissection: Improved Major Adverse Cardiovascular Events-Free Survival

Introduction: Cranio-Cervical Artery Dissection (CeAD) is a relatively common cause of cerebrovascular event in young subjects for which no clear treatment strategy is established. We evaluated the incidence of major adverse cardiovascular events (MACE) in CeAD patients treated with and without stent placement. Methods: COMParative effectiveness of treatment options in cervical Artery diSSection (COMPASS) is a single high-volume center prospective longitudinal registry that enrolled consecutive CeAD patients over a 2-year period. Patients were ≥18 years of age with confirmed extra- or intracranial CeAD on imaging. Enrolled participants were followed for 1-year evaluating MACE as the primary end-point. Results: One-hundred eleven patients were enrolled (age 53 ± 15.9, 56% Caucasian, 50% male, BMI 28.9 ± 9.2). Grade 1, 2, 3, and 4 blunt vascular injury noted in 16%, 33%, 19%, and 32%, respectively. Forty-percent of dissections were due to known trauma. A predisposing factor was noted in the majority (78%), including violent sneezing, carrying heavy load, sports/recreation activity, chiropractic manipulation, and abrupt/prolonged head rotation. Stent was placed in 11 (10%) subjects (extracranial carotid n=8; intracranial carotid n=2; extracranial vertebral n=2) at the physician’s discretion. Similar to the CADISS trial, there was no significant difference between antiplatelet/anticoagulant groups in terms of MACE. Stented patients experienced fewer MACE than non-stented patients (log rank p=0.1), as depicted in the Kaplan-Meier curve (Figure 1). The CeAD patients with stents did not experience any MACE events in the 1-year follow-up. Conclusion: In this single high-volume center cohort of CeAD patients, we report a promising strategy of MACE prevention using stent placement. This data will help sample size estimation for a future randomized trial.

5193Percutaneous coronary intervention provided better result than optimal medical therapy in patients with chronic total occlusion: a metanalysis

Abstract Background Studies comparing the outcome of percutaneous coronary intervention (PCI) along with optimal medical therapy (OMT) versus OMT alone in treatment of chronic total occlusion (CTO) are limited by observational design, variable follow up period, diverse clinical outcome, high drop-out and cross-over rate. Prematurely terminated DECISION CTO trail and the promising result of the most recent EUROCTO trial still left the quest unanswered. Previous metanalysis on the present context were restricted to studies with propensity-matched analysis only and did not incorporate the recent randomized trials. Purpose This study aims to conduct a meta-analysis of published data of observational as well as randomized studies comparing long term outcomes of PCI+OMT versus OMT alone. Methods The present protocol is registered in PROSPERO. PubMed, Embase and Cochrane databases were systematically reviewed. Fourteen studies meeting criteria were included in the meta-analysis. The Cochrane Risk of Bias scale was used to appraise the overall quality of the studies. Revman 5.3 software was used to analyse the data and random-effects model with inverse variance method was undertaken. R packages were used for assessment of bias and metaregression. Results Baseline parameters of both the groups were comparable. Major adverse cardiovascular events (MACE) which comprises of cardiac death, myocardial infarction, stroke, and unplanned revascularization [Figure 1] were significantly lower in the PCI+OMT group. (RR: 0.77; 95% CI: 0.61 to 0.97; P≤0.ehz746.00521; I2=85%). High heterogeneity was partially (14%) explained by age factor. However study design, follow up duration, LVEF, presence of TVD did not attribute significantly to heterogeneity, in isolation or any combination in metregression model. All cause mortality and cardiac death [Figure 2, 3 respectively] were significantly lower in the PCI+OMT group (P=0.29, p=0.63, respectively). Myocardial infarction (P=0.25) and stroke rates (P=0.15) were lower in the PCI+OMT group, however they did not reach statistical significance. Unplanned revascularization (of any vessel) showed a higher trend in the PCI+OMT group, without reaching statistical significance (P=0.46, I2=88%). Conclusion PCI of CTO is rewarded with better long term outcome, in terms of MACE and all-cause mortality but limited to greater unplanned revascularization. Acknowledgement/Funding None

279Clinical outcome after coronary bifurcation stenting: a systematic review and network meta-Analysis of PCI bifurcation techniques comprising 5572 patients

Abstract Background The optimal PCI technique for bifurcation lesions remains a matter of debate. Several RCT have compared different bifurcation PCI techniques. Provisional stenting has been recommended as the default technique for most bifurcation lesions. However, emerging data suggests that double-kissing crush technique can be considered in true left main bifurcation lesions and has been endorsed by the European Society of Cardiology Guidelines. Purpose To compare the clinical outcome between different bifurcation PCI techniques. Methods We searched MEDLINE for randomized clinical trials (RCT) comparing PCI bifurcation techniques for coronary bifurcation lesions. Outcomes of interest were major adverse cardiovascular events (MACE) defined as the composite of cardiac death, myocardial infarction (MI) and target vessel or lesion revascularization (TVR/TLR), and the individual components of MACE. Stent thrombosis was assessed as defined by the ARC. Stratification based on left-main or distal bifurcations was performed. We evaluated the studies' risk of bias in accordance to the Cochrane Handbook for Systematic Reviews of Interventions, and certainty of evidence using the Grading of Recommendations Assessment, Development and Evaluation framework. We estimated summary odds ratios (ORs) using pairwise and Bayesian network meta-analysis. Results We identified 263 studies and of these included 19 RCT including 5572 patients treated with 5 bifurcation PCI techniques namely provisional stenting, systematic T-stenting, crush, culotte and double-kissing crush. Median follow-up was 12 months (IQR 8 to 36). When all bifurcation lesions were combined, double-kissing crush technique reduced the occurrence of MACE (OR 0.42; CrI 0.28 to 0.61) compared to provisional stenting. This difference was driven by a reduction in TVR/TLR (OR 0.39; CrI 0.25 to 0.65). No differences were found in cardiac death, MI or stent thrombosis among analyzed PCI techniques. No differences in MACE were observed between provisional stenting, systematic T-stenting, crush. In distal bifurcations (n=17 studies, 4634 patients), double-kissing crush also showed to reduce MACE (OR 0.48; CrI 0.29 to 0.67 vs. Provisional). In left-main bifurcations (n=3 studies, 938 patients) no differences in MACE were found between PCI techniques. Conclusions In this network meta-analysis, PCI bifurcation techniques were similar with respect to the occurrence of cardiac death, myocardial infarction and stent thrombosis. When all coronary bifurcations were combined, an advantage of double-kissing crush was observed in terms of MACE driven by lower rate of repeated revascularization. Further studies are required to define the best PCI bifurcation technique for left main coronary artery disease.

Comparison of dedicated BIOSS bifurcation stents with regular drug-eluting stents for coronary artery bifurcated lesions: Pooled analysis from two randomized studies.

Coronary bifurcation treatment poses a therapeutic challenge. The aim of this study was to analyze pooled data of two randomized clinical trials, POLBOS I and POLBOS II, to compare 1-year follow-up results and identify possible prognostic factors. In POLBOS trials dedicated bifurcation BiOSS® stents were compared with regular drug eluting stents (rDES) in patients with stable coronary artery disease or non ST-segment elevation acute coronary syndrome (POLBOS I: paclitaxel eluting BiOSS® Expert vs. rDES; POLBOS II: sirolimus eluting BiOSS® LIM vs. rDES). Provisional T-stenting was the default strategy. Angiographic control was performed at 12 months. The primary endpoint was major adverse cardiovascular events (MACE) rate defined as the rate of cardiac death, myocardial infarction (MI) or target lesion revascularization (TLR). 445 patients, with 222 patients in the BiOSS group and 223 patients in the rDES group, were analyzed. In 26.7% cases procedures were performed within distal left main, and true bifurca-tions which accounted for 81.6% of treated lesions. At 12 months the whole population exhibited no statistical differences in terms of MACE, TLR, MI or cardiac death between rDES and BiOSS groups. In multivariate analysis odds for MACE decreased with female sex (OR 0.433, 95% CI 0.178-0.942, p = 0.047) and with proximal optimization technique use (OR 0.208, 95% CI 0.097-0.419, p < 0.001), whereas the odds for MACE increased with main vessel predilatation (OR 2.191, 95% CI 1.042-5.066, p = 0.049) and diabetes mellitus treated with insulin (OR 2.779, 95% CI 1.1-6.593, p = 0.024). Pooled data showed no significant difference between MACE and TLR rates for BiOSS® group vs. rDES group.

Effects of Statin Therapy on Clinical Outcomes of Survivors of Acute Myocardial Infarction with Severe Systolic Heart Failure

ObjectiveLarge randomized trials have failed to show a beneficial effect of statin treatment in chronic HF. The investigators tried to evaluate the long-term effects of statin therapy in patients with new onset heart failure (HF) following acute myocardial infarction (AMI).MethodsBetween January 2008 and December 2011, a total of 13,616 AMI patients were enrolled in the Korea Acute Myocardial Infarction Registry (KAMIR) which was a prospective, multi-center, nationwide, web-based database of AMI in Korea. From this database, we studied 1,055 patients with AMI who had newly developed severe acute HF [left ventricular ejection fraction ≤ 40%] and were discharged alive. The patients were divided into two groups, a statin group (n = 756) and a no-statin group (n = 299). We investigated the one-year major adverse cardiovascular events (MACEs), including all-cause mortality, MI, and any revascularization of each group. We then performed a propensity-score matched analysis.ResultsIn the original cohort, one-year MACEs were similar between the two groups (16.5% vs. 14.7% in the statin or no-statin groups; p = 0.47). Propensity-score matching yielded 256 pairs, and in that population we observed comparable results in terms of MACEs (18.0% vs. 12.5% in the statin or no-statin groups, p = 0.11) and mortality (5.1% vs. 3.5% in the statin or no-statin groups, p = 0.51). Cox-regression analysis revealed that statin therapy was not an independent predictor for occurrence of a MACE [Hazard ratio (HR) 1.11, 95% CI 0.79–1.57, p = 0.54] or all-cause mortality (HR 1.42, 95% CI 0.75–2.70, p = 0.28).ConclusionStatin therapy was not associated with a reduction in the long-term occurrence of MACEs or mortality in survivors of AMI with severe acute HF in this retrospective cohort study.