Terms Of Major Cardiovascular Events Research Articles

1027 CONGENITAL CORONARY ARTERY ABNORMALITIES: THE DIAGNOSTIC AND PROGNOSTIC VALUE OF CARDIAC COMPUTED TOMOGRAPHY

Abstract Introduction To the best of our knowledge, there are no previous univocal data on how CCT can accurately describe morphological variants and subtypes of congenital coronary artery abnormalities. Taking into consideration the extensive application of CCT in clinical practice in the last decades, it is not uncommon to have a congenital coronary artery anomaly detected at CCT. Thus, the study aim is to evaluate the diagnostic and prognostic impact of specific cardiac CT parameters in subjects with a diagnosis of congenital coronary artery anomalies. Material and Methods This is an intermediate evaluation of a prospective clinical registry on a population of subjects who underwent a cardiac computed tomography imaging evaluation in the period between January 2007 and October 2015 and were diagnosed to have a congenital coronary abnormality. For the present preliminary analysis only coronary anomalies of origin have been considered and 92 patients have been included. Follow-up have been collected either through a structured telephonic interview or through the evaluation of clinical records of subsequent hospitalization or ambulatory visits. Results The population enrolled in the present study has an average age of 63,0 ± 12,8 years (range 34 to 85 years), with a male prevalence of 69,6%. The left main artery is missing in 46 individuals (50%), with separate origin of LAD and LCX. Only two duplications (2.2%), one for the left coronary artery and one for the right coronary artery, have been discovered. Six participants (6.5%) had a non-coronary artery origin abnormalities and pulmonary artery was the site of origin in the majority of cases. 51 subjects (55,4%) have an anomalous origin of the coronary artery from a different coronary sinus and 50 subjects had also an anomalous course with the retro-aortic being the most common (30,4%). 11 participants (12,0%) displayed also an intramural segment and 16 (17,4%) had abnormal ostial morphology. The high take-off of the vessel was uncommon (3,3%). Age appears to be the only relevant characteristic; indeed, it displays a significant correlation both to MACE (OR 95% CI 1.03, 1.01-1.07; p=0.0349) and to all-cause of death (OR 95% CI 1.14, 1.02-1.27; p=0.0151). None of the traditional cardiovascular risk factors were found to be significantly linked with adverse outcomes in this study sample of coronary anomalies. Conclusions The result of this intermediate evaluation is that cardiac CT can be successfully used to define the anatomy and features of CAA. However, it demonstrated that in middle-aged patients, the tomographic finding of an abnormality of coronary origin might not have a meaningful, strong negative prognostic value in terms of major cardiovascular events and all-cause of death. This means that probably, in the majority of the cases, once the diagnosis is performed later on in life, no further systematic assessment is needed but a personalized approach should be suggested.

The Impact of Successful Percutaneous Coronary Intervention on the Reduction of Major Cardiovascular Events in Patients with Chronic Total Coronary Occlusion In dr. Saiful Anwar's Malang Hospital

Background: Chronic total coronary occlusion (CTOs) is associated with an increased risk of adverse clinical outcomes. The benefits of percutaneous coronary intervention (PCI) in CTO are still being debated due to the limited data available. This study aims to determine the relationship between the success of PCI in CTOs and the reduction of major cardiovascular events compared to those who failed or did not perform revascularization in patients with chronic coronary total occlusion in RSUD by Dr. Saiful Anwar Malang. Methods:This study is an analytic observational study with a retrospective cohort design. Of a total of 2165 patients who underwent angiography at Saiful Anwar Hospital, Malang, for the period August 2017–September 2020, consecutively, 578 patients with lesions of at least one CTO were found. There were 68 patients who were excluded, so 510 patients were analyzed in this study. They were divided into two groups, the CTO group that was successfully revascularized with PCI (n = 141) and the group that was not revascularized (n = 369). The outcome of this study was major cardiovascular events (MACE), which included cardiac mortality , all cause mortality, and rehospitalization events. Result: Patients with CTO who were not revascularized compared to those with revascularized CTO had a higher history of heart failure, involvement of LM disease, multivessel disease, and three vessel disease (41.2% vs 18.4%, p = 0.041; 16.5% vs 1.8%, p < 0.001; 69.4% vs 22.7%, p < 0.001; 56.5% vs 14.1%, p < 0.001) with a lower mean LVEF (0.49 ± 0.06 vs 0.51 ± 0.07, p=0.045) and older age (60±9 vs 57±8 years ; p=0.007).. At a 12-month follow-up, in the CTO group that was successfully revascularized by PCI, there was a better prognosis than the non-revascularized CTO group in terms of major cardiovascular events (19.9% vs 33.1% Plog-rank = 0.002). These results were consistent for all-cause mortality (5.5% vs 20.6%, Plog-rank =0.027), cardiac mortality (3.7% vs 20.6%, Plog-rank < 0.001) and rehospitalization events. (7.5% vs 32.2%, Plog-rank = 0.001). Conclusion: Successful revascularization of CTO by PCI may provide clinical benefits in patients with CTO in association with major cardiovascular events.

ROSS procedure versus mechanical valve replacement in young and middle-aged adults with aortic valve disease

Background: Aortic valve replacement (AVR) remains the only treatment that was revealed to advance the natural history in the cases with severe symptomatic aortic valve disorder. However, aortic valve diseases were challenging in young and adults in middle age persons. The aim of our study: was to compare the mid-term outcomes, quality of life and adverse valve- related events among patients undergoing the Ross procedure and those receiving a mechanical aortic valve . Patients and Methods: This study included patients with aortic valve disease divided into Fifty patients were candidates for ROSS procedure and the other Fifty were for mechanically aortic valve replacement after obtaining the approval of the local ethical committee. Results: Ross patients show statistically significant lower MLHFQ scores compared to Mechanical valve patients; however, a nonsignificant change was found among the study groups in terms of major cardiovascular events or mortality. Conclusion: Mechanical AVR is accompanied by low morbidities and mortalities in both the short and long term. Our data suggest that The Ross operation may be accomplished securely and reproducibly in properly particular cases with lower morbidity and mortality and better quality of life.

P332Comparative efficacy of intracoronary agents for acute treatment of coronary no-reflow: a network meta-analysis

Abstract Background Coronary no-reflow is a potentially lethal complication of percutaneous coronary intervention (PCI). There is a growing body of evidence on how to best prevent this condition by the proper stenting technique and other mechanical measures or adjunctive drug treatments. However, it is still controversial how to tackle coronary no-reflow when it occurs. Purpose We aimed to compare and rank intracoronary agents for acute treatment of coronary no-reflow by considering both indirect and direct evidence from the literature in a network meta-analysis. Methods We searched the databases PubMed, Embase and Central for randomised controlled trials of the acute treatment of coronary no-reflow following primary PCI in patients with ST-elevation myocardial infarction (STEMI) and non-STEMI. Trials with patients suffering from stable angina and/or receiving elective PCI, observational study design and no measure of coronary flow were excluded. Two blinded reviewers independently collected studies, assessed risk of bias with the Cochrane risk of bias tool and extracted data. The primary outcome was a measure of coronary flow immediately following the intervention (TIMI flow grade, TIMI frame count or myocardial bush grade), secondary outcome were major adverse cardiovascular events during follow-up. Pairwise and network meta-analysis were performed using the random-effects model within a frequentist framework. Results 8 studies with a total of 540 participants were identified, including 4 multi-arm studies. This enabled 19 pairwise comparisons of 12 different treatments, all administered via intracoronary route (ADE=adenosine, DIL=diltiazem, DIP=dipyridamole, NIT= nitroglycerin, NPR=nitroprusside, PLA=placebo, TIR=tirofiban, U+V=urokinase combined with verapamil, URA=urapidil, URO=urokinase, VER=verapamil X+T= Xuesaitong combined with tirofiban). Overall, risk of bias in these studies was rated moderate. For graphical representation of the network for the primary outcome, see left panel of the figure. It exhibited a low level of inconsistency and heterogeneity with a global I2 value of 20.9%. Among the different treatments, URA, X+T, and TIR were more effective in re-establishing coronary flow with the caveat that the results of URA depended on one singular trail with a large variance, see right panel of the figure. NIT was even slightly worse than placebo in the primary outcome, the other agents were equivalent with placebo. In terms of major cardiovascular events during follow-up, TIR exhibited a protective effect compared with placebo at borderline statistical significance (OR 0.3843 [95% CI 0.1488; 0.9923]. For URA, data on secondary outcome were not available. Conclusions Urapidil and Tirofiban are potentially effective candidate drugs for larger randomised controlled trials, which are needed to validate the sparse evidence that is available to date on the acute treatment of coronary no-reflow.

P3123Enoxaparin versus unfractionated heparin in ST-elevation myocardial infarction patients undergoing primary percutaneous coronary intervention

Abstract Background The use of intravenous enoxaparin (LBWH) in patients with ST-elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (pPCI) was upgraded in the latest European Guidelines to a class IIa recommendation. Purpose The authors aim to compare safety and prognostic impact of LMWH versus unfractionated heparin (UFH) use in STEMI patients undergoing primary PCI. Methods Retrospective study of 3875 STEMI patients who underwent pPCI between October 2010 and September 2017 and were included in a national multicenter registry. Group A consisted of patients managed only with LMWH, and Group B patients were treated with UFH regardless of eventual LMWH associated exposure. The groups were compared according to their demographic, clinical and laboratory characteristics. The primary endpoint (PE) results from a composite which included: procedural failure (pPCI failure or bailout use of GPIIb/IIIa inhibitors), in-hospital mortality, re-infarction or major bleeding (according to the registry criteria). The secondary endpoint (SE) included: in-hospital major bleeding, need for red blood cell transfusion, or haemoglobin drop ≥2g/dL. A 1:1 propensity score (PS) analysis was performed according to demographic variables, medical history and previous medication, physical examination, electrocardiogram characteristics and left ventricular function, matching 1558 of the 3875 patients for later comparison between groups. Results Overall, Group A included 1083 (27.9%) and Group B 2792 (72.1%) patients. The mean age was 63±14 years, and 33.5% of the cohort were female. Despite the baseline characteristics heterogeneity between groups, this phenomenon was not observed after PS matching. The PE was more frequent in Group A, without reaching statistical relevance (15.6% vs 13.3%, p=0.07). The SE was superior in Group A (34.4 vs 29.4%, p=0.01). According to the PS matching analysis, there were no differences beetween groups in terms of the PE (13.9% vs 12.0%, p=0.28), while the SE kept more frequent among Group A (34.9% vs 28.5%, p=0.02) [Figure]. Propensity score: group comparison Conclusion In this study based on a national multicentric registry of STEMI patients, the use of LMWH was not associated with better in-hospital prognosis in terms of major cardiovascular events and was related with higher rates of bleeding related events in the scenario of pPCI, compared to UFH. According to these results, further studies are required to support the widespread use of LMWH in this clinical scenario.

Heart failure risk and major cardiovascular events in diabetes: an overview of within-group differences in non-insulin antidiabetic treatment.

Recently, great attention is paid to cardiovascular impact of non-insulin glucose-lowering drugs, particularly in terms of major cardiovascular events and risk of heart failure. In this regard, a surprising diversity among different molecules within the same pharmacological class has been noticed, yielding to an intra-class discrepancy which has no analogous in other cardiovascular fields. The aim of this paper is to review the literature, giving an insight of the heterogeneous effects among groups and within group shown by oral antidiabetic drugs, with a special concern to fragile patients, such as those with or at risk of heart failure.

Sirolimus- vs. paclitaxel-eluting stents in patients undergoing off-label percutaneous coronary intervention

Studies of percutaneous coronary intervention (PCI) with drug-eluting stents in high-risk scenarios are often limited by short follow up and use definitions of "off-label" PCI which do not entirely mirror insert packages recommendations. We analyzed the incidence of cardiovascular events in 1050 consecutive patients undergoing off-label PCI with sirolimus- (n=581) or paclitaxel- (n=469) eluting stents. At 3 years, there were no differences between groups in terms of major cardiovascular events (adjusted hazard ratio 0.991; 95% CI, 0.758 to 1.295; p=0.945), despite slightly higher rates of myocardial infarction and late stent thrombosis seen among patients who received paclitaxel-eluting stents.

Approaches to Prevention of Cardiovascular Complications and Events in Diabetes Mellitus

Diabetes mellitus affects about 8% of the adult population. The estimated number of patients with diabetes, presently about 170 million people, is expected to increase by 50-70% within the next 25 years. Diabetes is an important component of the complex of 'common' cardiovascular risk factors, and is responsible for acceleration and worsening of atherothrombosis. Major cardiovascular events cause about 80% of the total mortality in diabetic patients. Diabetes also induces peculiar microangiopathic changes leading to diabetic nephropathy conducive to end-stage renal failure, and to diabetic retinopathy that may progress to vision loss and blindness. In terms of major cardiovascular events, coronary heart disease and ischaemic stroke are the main causes of morbidity and mortality in diabetic patients. Peripheral arterial disease frequently occurs, and is more likely to be conducive to critical limb ischaemia and amputation than in the absence of diabetes. Although there are a number of differences in the pathogenesis and clinical features of diabetic macroangiopathy and microangiopathy, these two entities often coexist and induce mutually worsening effects. Endothelial injury, dysfunction and damage are common starting points for both conditions. Causes of endothelial injury can be distinguished into those 'common' to nondiabetic atherothrombosis, such as hypertension, dyslipidaemia, smoking, hypercoagulability and platelet activation; and those more specific and in some cases 'unique' to diabetes and directly related to the metabolic derangement of the disease, such as (i) desulfation of glycosaminoglycans (GAGs) of the vascular matrix; (ii) formation of advanced glycation end-products (AGE) and their endothelial receptors (RAGE); (iii) oxidative and reductive stress; (iv) decline in nitric oxide production; (v) activation of the renin-angiotensin aldosterone system (RAAS); and (vi) endothelial inflammation caused by glucose, insulin, insulin precursors and AGE/RAGE. Prevention of major cardiovascular events with the antithrombotic agent aspirin (acetylsalicylic acid) is widely recommended, but reportedly underutilised in patients with diabetes. However, some data suggest that aspirin may be less effective than expected in preventing cardiovascular events and especially mortality in patients with diabetes, as well as in slowing progression of retinopathy. In contrast, a recent study found picotamide, a direct thromboxane inhibitor, to be superior to aspirin in diabetic patients. Clopidogrel was either equivalent or less active in diabetic versus nondiabetic patients, depending upon different clinical settings.Recent studies have shown that some GAG compounds are able to reduce micro- and macroalbuminuria in diabetic nephropathy, and hard exudates in diabetic retinopathy, but it is as yet unknown whether these agents also influence the natural history of microvascular complications of diabetes. Lifestyle changes and physical exercise are also essential in preventing cardiovascular events in diabetic patients. Available data on the control of the metabolic state and the main risk factors show that careful adjustment of blood sugar and glycated haemoglobin is more effective in counteracting microvascular damage than in preventing major cardiovascular events. The latter objective requires a more comprehensive approach to the whole constellation of risk factors both specific for diabetes and common to atherothrombosis. This approach includes lifestyle modifications, such as dietary changes and smoking cessation and the use of HMG-CoA reductase inhibitors (statins), which are able to correct the lipid status and to prevent major cardiovascular events independently of the baseline lipidaemic or cardiovascular status. Tight control of hypertension is essential to reduce not only major cardiovascular events but also microvascular complications. Among antihypertensive measures, blockade of the RAAS by means of ACE inhibitors or angiotensin II receptor antagonists recently emerged as a potentially polyvalent approach, not only for treating hypertension and reducing cardiovascular events, but also to prevent or reduce albuminuria, counteract diabetic nephropathy and lower the occurrence of new type 2 diabetes in individuals at risk.