2021 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization: Executive Summary: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines

Revascularization in Diabetic Patients With Non-ST-Elevation Acute Myocardial Infarction

Objective

To compare the outcomes of diabetic patients hospitalized with non-ST-elevation myocardial infarction (NSTEMI) referred for coronary artery bypass graft (CABG) or percutaneous coronary intervention (PCI) in a real-world evidence population.

Patients and Methods

This study assessed major cardiovascular outcomes in diabetic patients who underwent myocardial revascularization, using data obtained on July 24, 2024, from TriNetX, a global health research network. Patients with diabetes mellitus and NSTEMI were identified using the International Classification of Diseases, Tenth Revision, diagnosis code. Main outcome measure was 5-year all-cause mortality. Proportional hazards regression and propensity score matching were used to adjust outcomes for key patients.

Results

A total of 18,115 patients with a mean age of 62.2 (SD, 8.98) years and a mean glycated hemoglobin A1c of 7.66% (SD, 2.18%) were included, of whom 8206 (45.3%) underwent CABG and 9909 (54.7%) underwent PCI. During the 5-year follow-up, 2275 (12.5%) deaths were recorded in all cohort. Propensity matching yielded a 1:1 match consisting of 7585 patients in each group (CABG vs PCI); CABG was associated with significantly lower all-cause mortality over 5 years of follow-up (10.6% vs 17.9%; hazard ratio, 0.685; 95% CI, 0.618-0.759; P<.0001). Myocardial infarction occurred more frequently in the PCI cohort (48.6% vs 43.3%; P<.0001). Additional coronary revascularization was higher for PCI patients at 5 years (14.5% vs 1.72%; P=.0229).

Conclusion

In this real-world study of diabetic patients with NSTEMI, CABG was associated with a lower rate of all-cause mortality at 5 years when compared with PCI.

Drug-coated balloons versus drug-eluting stents in patients with small coronary artery disease: an updated meta-analysis

BACKGROUND

Drug-coated balloons (DCB) have promising results in the management of large coronary artery lesions (CAD), still their role in treating small CAD is not well established. We aimed to provide a comprehensive appraisal of the efficacy and safety of DCBs in patients with small CAD.

METHODS

We searched PubMed, Scopus, web of science, Ovid, and Cochrane Central from inception until 30 March, 2023. We included all relevant studies that compared DCB versus drug-eluting stents (DES) in small CAD patients undergoing PCI. We reported clinical outcomes as MACE, all-cause death, cardiac death, MI, TLR, TVR, and stent thrombosis, while angiographic outcomes were late lumen loss (LLL), mean lumen diameter (MLD), net luminal gain (NLG), and in-segment binary restenosis.

RESULTS

Twenty studies comprising 18,469 patients were included in this meta-analysis. The incidence rate of MACE was 9.4% in the DCB group compared to 9.9% in the DES group, without a significant difference in the risk of MACE (OR = 0.97, 95% CI: 0.77 to 1.22, p = 0.78). Moreover, DCB significantly decreased MLD and NLG compared to DES, with the following values, respectively (MD= -0.19, 95% CI: -0.32 to -0.06, p < 0.001, and MD -0.21, 95% CI: -0.40 to -0.01, p = 0.04). On the other hand, DCB was associated with higher odds in the risk of in-segment binary restenosis (OR 1.66, 95% CI: 1.03 to 2.68, p = 0.04).

CONCLUSION

DCB is an alternative approach to DES in the management of small CAD and should be validated in daily clinical practice.

PROSPERO REGISTRATION

CRD42023413068.

Use of Intravascular Ultrasound During Peripheral Vascular Interventions for Claudication Is Not Associated with Improved Outcomes

INTRODUCTION AND OBJECTIVES

The efficacy of intravascular ultrasound (IVUS) for improving outcomes of peripheral vascular interventions (PVI) has not been well studied. We aimed to evaluate the association of IVUS with long-term outcomes in patients undergoing PVI for claudication.

METHODS

We conducted a two-cohort study using data from 100% of Medicare fee-for-service claims (2018-2022) and the Vascular Quality Initiative Vascular Implant Surveillance and Interventional Outcomes Network (VISION; 2016-2019). For both cohorts, we identified all patients who underwent an index (first-time) femoropopliteal PVI for claudication, excluding patients with chronic limb-threatening ischemia (CLTI) and acute limb ischemia. We compared IVUS use over time and by procedure type and setting. We used multivariable Cox proportional hazards models to assess the associations of IVUS with repeat PVI, conversion to CLTI, and amputation. For the Medicare cohort, adjustments were made for baseline patient characteristics, while for the VISION cohort, additional adjustments were made for detailed anatomic factors. All models were clustered by physician.

RESULTS

In the Medicare dataset, 69,092 patients (median age 74 years; 40.5% female; 12.1% non-Hispanic Black) underwent an index femoropopliteal PVI for claudication, of whom 22.1% (N=15,253) received IVUS. In the VISION dataset, 6,722 patients (median age 72 years; 38.7% female; 11.6% non-Hispanic Black) underwent an index femoropopliteal PVI for claudication, of whom 3.8% (N=254) received IVUS. The mean follow-up time for both cohorts was 2.7 years. For both the Medicare and VISION cohorts, IVUS use significantly increased over time, particularly in ASC/OBL settings and in conjunction with atherectomy procedures (P<0.001). In the Medicare cohort, IVUS use was associated with a higher hazard of repeat PVI (aHR 1.07, 95% CI 1.02-1.12) and progression to CLTI (aHR 1.11, 95% CI 1.03-1.20) after adjustment compared to PVI without IVUS. In the VISION cohort, there were no significant differences in outcomes between IVUS and non-IVUS cases (all, P>0.05).

CONCLUSIONS

The use of IVUS for the treatment of claudication is rapidly increasing, without clear benefits in outcomes. The role of IVUS in treating claudication deserves further investigation.

Comparison of distal and conventional transradial access on procedure duration and radiation exposure in carotid artery stenting

OBJECTIVE

This study aimed to assess the effects of distal transradial access (dTRA) compared to conventional transradial access (cTRA) on procedure duration and radiation exposure among patients undergoing carotid artery stenting.

METHODS

The study included 131 patients who underwent cerebrovascular interventional diagnosis and treatment in the Department of Cerebrovascular Diseases at Beijing Anzhen Hospital, Capital Medical University, from January 2022 to April 2024. Patients were categorized into dTRA and cTRA groups based on the puncture site. Clinical and laboratory data, operation duration, and the incidence of puncture-related complications and perioperative adverse events were recorded. Procedure duration and radiation exposure levels were then compared between the two groups.

RESULTS

The dTRA group comprised 47 patients and the cTRA group comprised 84 patients. No statistically significant differences were observed between the groups in terms of risk factors and laboratory parameters (all P > 0.05). Procedure-related comparisons between the dTRA and cTRA groups showed that the operation time for carotid artery stenting was (51.47 ± 10.51) minutes and (50.08 ± 11.37) minutes, respectively; the fluoroscopy time was (20.48 ± 5.55) minutes and (20.96 ± 9.24) minutes, respectively; and the radiation exposure dose was (573.60 ± 185.17) mGy and (567.09 ± 329.96) mGy, respectively. None of these differences were statistically significant (all P > 0.05).

CONCLUSION

The results suggest that dTRA is comparable to cTRA in terms of procedure duration and radiation exposure during carotid artery stenting.

Prominent Right Ventricular Tracer Uptake: A Harbinger of Multivessel Coronary Artery Disease

A 65-y-old woman with multiple cardiovascular risk factors presented with atypical chest pain, prompting a 1-d pharmacologic stress myocardial perfusion test using 99mTc sestamibi. Initial interpretation suggested ischemia, but closer inspection revealed increased right ventricular uptake and increased left ventricular chamber size at stress, indicative of significant 3-vessel coronary artery disease (CAD). These findings were confirmed by cardiac catheterization, showing 3-vessel disease, including significant left main CAD. The patient underwent coronary artery bypass graft surgery. This case highlights the importance of meticulous SPECT image interpretation, particularly focusing on right ventricular uptake and transient ischemic dilation, to accurately diagnose severe CAD and improve cardiovascular outcomes.

Comparison of very early-phase vascular response to the CD34 antibody‑covered sirolimus‑eluting stent versus durable polymer-coated everolimus-eluting stent

The COMBO stent is a unique biodegradable polymer sirolimus-eluting stent with an anti-CD34 antibody coating that captures endothelial progenitor cells and potentially promotes vessel healing. There are limited data regarding strut tissue coverage at the very short-term period after COMBO stent implantation compared to other types of drug-eluting stents in the same patient. This prospective study enrolled patients who had COMBO Plus stent and durable polymer-coated everolimus-eluting stent (XIENCE stent) implanted simultaneously in the same vessel for long coronary lesions. Strut tissue coverage within 1 month after implantation was compared using optical coherence tomography. Struts fully covered with tissue were defined as covered, and healthy tissue coverage was defined as tissue thickness with ≥ 40 μm. A total of 21 patients, 11 (52%) of whom presented with acute coronary syndrome, were enrolled. A total of 4798 struts from 21 COMBO Plus stents and 4608 struts from 21 XIENCE stents were analyzed at an average of 19.8 ± 6.5 days after implantation. In the lesion-level analysis, covered struts were more frequently observed (83.7 ± 7.4% vs. 76.9 ± 11.0%, P < 0.01), and the rate of healthy tissue coverage tended to be higher (49.9 ± 17.7% vs. 42.1 ± 20.5%, P = 0.07) in the COMBO Plus stent compared to the XIENCE stent. Strut tissue coverage was more advanced in the COMBO Plus stent compared to the XIENCE stent at the very short-term period after implantation.

Myocardial flow reserve derived from D-SPECT for evaluating non-culprit ischemic lesions in STEMI patients: comparison with quantitative flow ratio

OBJECTIVES

This study sought to elucidate the diagnostic performance and concordance between myocardial flow reserve (MFR) derived from dynamic single-photon emission computed tomography (D-SPECT) and quantitative flow ratio (QFR) in evaluating non-culprit ischemic lesions following ST-elevation myocardial infarction (STEMI). Additionally, the study investigated the integration of MFR with angiographic microvascular resistance (AMR) derived from coronary angiography to determine its utility in screening and stratifying non-culprit ischemic lesions.

BACKGROUND

The diagnostic performance and agreement between MFR and QFR in evaluating non-culprit ischemic lesions in STEMI patients with multivessel disease are unknown.

METHODS

This research encompassed a cohort of 106 STEMI patients with at least 1 intermediate non-culprit ischemic lesion, characterized by 40-80% diameter stenosis. After undergoing percutaneous coronary intervention, patients were evaluated using QFR and, approximately five days later, underwent D-SPECT to assess myocardial blood flow (MBF) and MFR. MFR was evaluated against QFR as a reference for diagnostic performance and agreement, including sensitivity analysis in vessels with normal microvascular function. Furthermore, MFR, combined with AMR, effectively screened and stratified non-culprit ischemic lesions. Non-culprit ischemic lesions were defined by QFR ≤ 0.80 and normal microvascular function by AMR < 255 mmHg*s/m.

RESULTS

Among non-culprit lesions, MFR predicted a QFR ≤ 0.80 with a sensitivity of 85%, specificity of 86%, and accuracy of 86%. The positive predictive value was 56%, and the negative predictive value was 96%. The MFR cut-off was 1.93, with an area under the receiver operating characteristic curve of 0.90 (95% CI: 0.84 to 0.94). MFR showed similar diagnostic performance in patients with normal microcirculation. Moreover, low MFR with normal AMR indicated non-culprit ischemic lesions caused solely by epicardial narrowing, while low MFR with abnormal AMR indicated ischemic lesions complicated by microvascular dysfunction.

CONCLUSION

MFR derived from D-SPECT exhibits good diagnostic performance and moderate agreement in identifying non-culprit ischemic lesions in patients with STEMI. Combining AMR with MFR effectively screens and stratifies non-culprit ischemic lesions.

TRIAL REGISTRATION

ChiCTR.org.cn. ChiCTR2200059934. Registered 13 May 2022.

Evaluation of the Safety and Biocompatibility of a New Galvanized Vascular Stent in a Rabbit Atherosclerosis Model

OBJECTIVE

Compared to traditional pure zinc stents, the new galvanized vascular stent (GVS) combines the mechanical advantages of cobalt-chromium alloy with the biological functions of zinc. This study aims to evaluate the safety and biocompatibility of the GVS in a rabbit atherosclerosis model.

METHODS

A rabbit atherosclerosis model was established using a high-fat diet, and a galvanized cobalt-chromium alloy stent was implanted in the abdominal aorta. The experimental animals were followed up at 1, 3, and 6 months post-surgery. Safety was assessed through hematological parameters and histopathological analysis, and scanning electron microscopy and tissue section staining were used to evaluate re-endothelialization and intimal hyperplasia in the stented arterial segment. Proteomics was employed to uncover potential molecular mechanisms.

RESULTS

At each time point following GVS implantation, no significant abnormalities were observed in hematological parameters or histopathological examination of major organs. No significant restenosis was observed in the stented segment at 6 months post-implantation. A complete endothelial layer was formed on the stent surface at 1 month post-surgery, and the stent remained fully covered at 6 months. The intimal thickness adjacent to the stent struts gradually increased post-surgery but showed no significant pathological hyperplasia. Proteomics suggests that the GVS may promote vascular repair through signaling pathways such as PI3K-Akt, cGMP-PKG, and cAMP and may have potential advantages in inducing macrophage polarization to the anti-inflammatory M2 type and inhibiting oxidative stress responses.

CONCLUSION

The GVS demonstrates good safety and biocompatibility in a rabbit atherosclerosis model.

Bi-variational physics-informed operator network for fractional flow reserve curve assessment from coronary angiography

The coronary angiography-derived fractional flow reserve (FFR) curve, referred to as the Angio-FFR curve, is crucial for guiding percutaneous coronary intervention (PCI). The invasive FFR is the diagnostic gold standard for determining functional significance and is recommended to complement coronary angiography. The invasive FFR curve can quantitatively define disease patterns. The Angio-FFR curve further overcomes the limitation of invasive FFR measurement and thus emerges as a promising approach. However, the Angio-FFR curve computation suffers from a lack of satisfactory trade-off between accuracy and efficiency. In this paper, we propose a bi-variational physics-informed neural operator (BVPINO) for FFR curve assessment from coronary angiography. Our BVPINO combines with the variational mechanism to guide the basis function learning and residual evaluation. Extensive experiments involving coronary angiographies of 215 vessels from 184 subjects demonstrate the optimal balance of BVPINO between effectiveness and efficiency, compared with computational-based models and other machine/deep learning-based models. The results also provide high agreement and correlation between the distal FFR predictions of BVPINO and the invasive FFR measurements. Besides, we discuss the Angio-FFR curve assessment for a novel gradient-based index. A series of case studies demonstrate the effectiveness and superiority of BVPINO for predicting the FFR curve along the coronary artery centerline.

Gender disparities in cangrelor usage for the treatment of patients with acute coronary syndrome undergoing percutaneous coronary intervention

BACKGROUND

Cangrelor is a rapid, potent intravenous P2Y12 inhibitor that reduces thrombotic and ischemic events in patients with myocardial infarction (MI) undergoing percutaneous coronary intervention (PCI). This study aimed to investigate gender disparities in Cangrelor usage, efficacy, and safety across gender in patients presenting with acute coronary syndrome (ACS) undergoing PCI.

METHODS

This is an observational retrospective analysis included patients presented with ACS who underwent PCI and received Cangrelor at MedStar Washington Hospital Center (2018-2023). Access to Cangrelor across gender was recorded. The primary safety outcome was in-hospital thrombolysis in myocardial infarction (TIMI) major bleeding, while the primary efficacy outcome was in-hospital major adverse cardiac events (MACE): defined as the composite of in-hospital cardiac death, MI, and stroke. A control group was investigated gender disparities in patients with ACS who did not receive Cangrelor.

RESULTS

A total of 2859 patients with ACS underwent PCI (991 women and 1868 men). Among these patients, women were less likely to receive Cangrelor during PCI compared to men (40.2 % vs. 48 %; P < 0.001). The Cangrelor cohort consisted of 1295 patients (398 women, 897 men), and among those, women had significantly higher rates of in-hospital TIMI major bleeding (3.5 % vs. 0.6 %; P < 0.001) and higher in-hospital MACE (5.0 % vs. 1.3 %; P < 0.001) compared to men. Multivariate modeling after adjusting for differences in baseline characteristics showed that women were associated with increased TIMI major bleeding (OR 4.02, 95 %CI 1.09-14.79; P 0.037), but not in-hospital MACE (OR 2.11, 95 %CI 0.88-5.07; P 0.096). In the non-Cangrelor cohort, there were no significant difference between women and men in TIMI major bleeding (0.8 % vs. 0.9 %, P = 0.865) and MACE (1.5 % vs. 1.6, P = 0.842).

CONCLUSION

In patients presenting with ACS, women who received cangrelor had higher rates of TIMI major bleeding, without an impact on MACE. This may partially explain why women with ACS undergoing PCI receive less cangrelor compared to men. Therefore, increased bleeding events in women receiving cangrelor warrant further investigation.

Myocardial Revascularization in Patients with Diabetes and Heart Failure-A Narrative Review

Heart failure and diabetes mellitus are major contributors to global morbidity and mortality, with their prevalence continuously rising, primarily due to aging populations and improvements in healthcare. These conditions often coexist or develop sequentially, leading to complex interactions that significantly influence the progression and management of both diseases. Furthermore, heart failure and diabetes are commonly associated with coronary artery disease, which presents a unique challenge in clinical management, particularly in the context of myocardial revascularization. The presence of diabetes exacerbates atherosclerotic progression and impairs endothelial function, while heart failure complicates the perfusion and recovery of myocardial tissue post-intervention. This narrative review delves into the underlying mechanisms contributing to revascularization failure in patients with heart failure and diabetes, emphasizing the importance of understanding these interactions for optimal treatment. The review also summarizes key findings from randomized controlled trials, examining evidence both in the general population and in specific subgroups, including the elderly and patients with left main coronary artery disease, chronic kidney disease, peripheral artery disease, and chronic obstructive pulmonary disease. Understanding these complexities is critical for improving patient outcomes.

De-escalating Dual Antiplatelet Therapy to Ticagrelor Monotherapy in Acute Coronary Syndrome : A Systematic Review and Individual Patient Data Meta-analysis of Randomized Clinical Trials

BACKGROUND

The role of transitioning from short dual antiplatelet therapy (DAPT) to potent P2Y12 inhibitor monotherapy in patients with acute coronary syndrome (ACS) undergoing drug-eluting stent (DES) implantation remains inconclusive.

PURPOSE

To compare the effects of de-escalating DAPT to ticagrelor monotherapy versus standard DAPT from randomized clinical trials in patients with ACS.

DATA SOURCES

PubMed, EMBASE, Scopus, and ClinicalTrials.gov from inception to 12 December 2024.

STUDY SELECTION

Randomized clinical trials comparing de-escalating DAPT to ticagrelor monotherapy versus ticagrelor-based standard DAPT for 12 months, specifically in patients with ACS undergoing DES implantation.

DATA EXTRACTION

The coprimary end points were an ischemic end point (composite of death, nonprocedural [spontaneous] myocardial infarction, or stroke) and a bleeding end point (Bleeding Academic Research Consortium types 3 or 5 bleeding).

DATA SYNTHESIS

Individual patient data were obtained from 3 trials (TICO [Ticagrelor Monotherapy After 3 Months in the Patients Treated With New Generation Sirolimus-Eluting Stent for Acute Coronary Syndrome], T-PASS [Ticagrelor Monotherapy in Patients Treated With New-Generation Drug-Eluting Stents for Acute Coronary Syndrome], and ULTIMATE-DAPT [Ticagrelor alone versus ticagrelor plus aspirin from month 1 to month 12 after percutaneous coronary intervention in patients with acute coronary syndromes]), including 9130 randomized patients with ACS; 3132 had ST-segment elevation myocardial infarction (STEMI), 3023 had non-STEMI (NSTEMI), and 2975 had unstable angina. The rate of the primary ischemic end point was not different between the ticagrelor monotherapy and standard DAPT groups (1.7% vs. 2.1%; hazard ratio [HR], 0.85 [95% CI, 0.63 to 1.16]). The rate of the primary bleeding end point was lower in the ticagrelor monotherapy group (0.8% vs. 2.5%; HR, 0.30 [CI, 0.21 to 0.45]). These findings were consistent in patients with STEMI, NSTEMI, and unstable angina.

LIMITATION

Other de-escalation strategies for modulating antiplatelet therapy were not included.

CONCLUSION

In patients with ACS undergoing DES implantation, de-escalating DAPT to ticagrelor monotherapy was associated with a lower risk for major bleeding compared with standard DAPT, without an increase in ischemic events, regardless of the type of ACS.

PRIMARY FUNDING SOURCE

None. (PROSPERO: CRD42024565855).

Future of factor XI inhibitors in cardiovascular practice

Anticoagulation is indicated for treatment and prevention of arterial and venous thrombosis. Targeting different steps of the coagulation process, currently available anticoagulants entail an increased risk of bleeding, which detrimentally impacts on prognosis and hinders the administration of an effective antithrombotic regimen. Factor XI (FXI) inhibition has emerged as a strategy to uncouple prevention of thrombosis from bleeding. Indeed, while FXI is crucial for the amplification phase in pathological thrombosis, it is ancillary in physiological hemostasis. A comprehensive search in several scientific databases has been performed to identify relevant studies in the field. In addition, ongoing trials have been searched for in proper datasets to provide an updated and comprehensive assessment of the current state of investigations on FXI inhibition. Many compounds have been tested to inhibit FXI at different stages (i.e., synthesis, activation, or interactions with target molecules and coagulation factors). These include antisense oligonucleotides, monoclonal antibodies, small molecules, natural peptides and aptamers. In phase 2 studies, FXI inhibitors reduced thrombotic complications without any corresponding increase in bleeding. FXI inhibitors were noninferior and potentially superior to low-molecular-weight heparin in orthopedic surgery and reduced bleeding compared to apixaban in patients with atrial fibrillation. FXI inhibition is also under testing in other conditions, including end-stage renal disease, cancer, or noncardioembolic stroke. FXI inhibition represents a promising and rapidly emerging approach for a number of clinical indications. This article reviews the rationale, evidence, pharmacology, and future applications of FXI inhibition.

Angiographic Quantitative Flow Ratio-Guided Treatment of Patients With Physiologically Intermediate Coronary Lesions

BACKGROUND

The FAVOR III (Comparison of Quantitative Flow Ratio Guided and Angiography Guided Percutaneous Intervention in Patients With Coronary Artery Disease) China trial reported improved clinical outcomes with percutaneous coronary intervention guided by quantitative flow ratio (QFR) compared with angiography. Whether these benefits also apply for patients presenting with "uncertainty-zone" lesions of intermediate physiological significance is uncertain. This study aims to examine the impact of QFR guidance versus angiography guidance on the management and outcomes of percutaneous coronary intervention in uncertainty-zone lesions.

METHODS AND RESULTS

In this prespecified subgroup analysis, offline QFR assessment categorized 873 patients (22.9%) into the uncertainty-zone subgroup, defined as having an offline QFR of 0.75 to 0.85 in all coronary arteries with a lesion causing ≥50% diameter stenosis. At 2 years, the rate of major adverse cardiac events, a composite of all-cause death, myocardial infarction, or ischemia-driven revascularization, occurred in 31 patients (7.0%) in the QFR-guided group and 35 patients (8.3%) in the angiography-guided group (hazard ratio [HR], 0.85 [95% CI, 0.52-1.37]). In landmark analysis, the relative treatment effect of QFR guidance versus angiography guidance on major adverse cardiac events differed before 1 year (4.7% versus 3.8%; HR, 1.25 [95% CI, 0.65-2.40]) and after 1 year (2.3% versus 5.5%; HR, 0.41 [95% CI, 0.20-0.87]) (Pinteraction=0.03), driven by fewer nonprocedural myocardial infarctions and ischemia-driven revascularizations in the QFR-guided group after 1-year follow-up.

CONCLUSIONS

In the modest-sized subgroup of patients with physiologically intermediate lesions randomized in the FAVOR III China trial, 2-year clinical outcomes were not significantly improved with a QFR-guided revascularization strategy compared with angiography guidance.

REGISTRATION

URL: https://www.clinicaltrials.gov; Identifier: NCT03656848.

Management and outcomes of patients with ST-elevation myocardial infarction and liver disease-Insights from the Nationwide Readmissions Database

Background

The association between cardiovascular disease and advanced liver disease is incompletely understood. To explore this interaction, we compared management, clinical outcomes, readmission rates, and resource utilization in ST-elevation myocardial infarction (STEMI) patients with and without liver disease.

Methods

The Nationwide Readmissions Database (2016-2020) was queried to identify hospitalizations for STEMI. Cohorts were stratified by presence of liver disease. Liver disease was defined as documented diagnosis of liver cirrhosis or liver failure. Multivariable regression model and propensity score matching was used to compare the risk of outcomes.

Results

Among 1,029,608 hospitalizations for STEMI; 45,478 (4.4 %) patients had a history of significant liver disease. Patient with liver disease had higher baseline prevalence of diabetes, chronic kidney disease, anemia, and heart failure. After propensity matching (N = 24,067 in each group), patients with liver disease had higher in-hospital mortality (48.8 % vs 17.3 %, aOR: 6.80 [CI: 6.55-7.06], p < 0.001) and adverse events, including cerebrovascular accidents (6.8 % vs 4.4 %, aOR:1.74 [CI: 1.62-1.86], p < 0.001), cardiac arrest (24.4 % vs 10.3 %, aOR:3.34 [CI: 3.21-3.48], p < 0.001), cardiogenic shock (55.9 % vs 21.1 %, aOR: 6.4 [CI: 6.18-6.64], p < 0.001), mechanical circulatory support requirement (36.2 % vs 14.4 %, aOR: 4.2 [CI: 4.01-4.34], p < 0.001), and major adverse cardiovascular and cerebrovascular events (61.1 % vs 25.3 %, aOR:6.5 [CI: 6.28-6.75], p < 0.001). From 2016 to 2020, in-hospital mortality for STEMI did not change significantly for patients with liver disease (47.4 % to 48.6 % p-trend: 0.826), however percutaneous coronary intervention (PCI) use increased from 43.6 % to 52.2 % (p-trend <0.001).

Conclusion

In STEMI hospitalizations, patients with liver disease have significantly higher mortality, and adverse events as compared with those without liver disease. Despite the increasing use of primary PCI, mortality remains high in STEMI patients with liver disease.

Coronary artery disease with heavily calcified lesions - literature review of novel therapeutic methods

Coronary artery disease and atherosclerosis are a very significant and widespread problem in modern medicine. The development of current diagnostics and treatment of atherosclerotic lesions is moving towards minimally invasive methods. The purpose of this article is to present selected novel methods of treating coronary atherosclerosis, comparing their effectiveness, indications, contraindications, and possible complications. A literature review of selected treatment methods for calcified atherosclerotic lesions was conducted in the online databases of PubMed, PubMed Central, Google Scholar, and NCBI. It includes original and review papers. The main language of the articles was English. The search used keywords such as "coronary artery disease," "calcified atherosclerotic lesions," "rotational atherectomy," "intravascular lithotripsy," and "RotaTripsy," as well as related phrases. After analyzing the abstracts, the papers that most closely matched the stated topic were selected. Atherosclerosis is the leading cause of coronary heart disease incidence. Several risk factors, both non-modifiable and modifiable, predispose to its occurrence. Heavily calcified atherosclerotic plaques are associated with a higher risk of coronary artery disease consequences. Currently, methods such as CT coronary angiography and optical coherence tomography are used for diagnosis. Endovascular therapies are now recommended for the treatment of atherosclerosis with heavily calcified plaques. Rotational atherectomy, intravascular lithotripsy and RotaTripsy are promising methods for treating high-grade atherosclerosis with calcified deposits. However, especially in the case of RotaTripsy, further clinical studies are required to better evaluate the efficacy of this novel method.

Outcomes After Noncardiac Surgery Performed Within 2 Years of Percutaneous Coronary Intervention

BACKGROUND

Limited data exist on noncardiac surgery patients with prior percutaneous coronary intervention (PCI) in the contemporary era. The objective was to examine rate, characteristics, and outcomes of patients who underwent noncardiac surgery within 2 years of PCI and develop a risk model of factors that predict long-term postoperative outcomes among patients with recent PCI.

METHODS AND RESULTS

Patients in the Veterans Affairs Surgical Quality Improvement Program database who underwent noncardiac surgery between October 1, 2017 and September 30, 2021 were included. Patients with versus without PCI within 2 years were propensity matched to examine major adverse cardiovascular events (MACE), defined as a 1-year composite of mortality, revascularization, and rehospitalization for myocardial infarction or stroke. Among patients with recent PCI, multivariable logistic regression was used to develop a risk model to predict 1-year postoperative MACE. Among 334 828 patients undergoing surgery, 2297 (0.68%) had PCI within 2 years. Among 9160 propensity-matched veterans, there was no difference in MACE between patients with and without preceding PCI (hazard ratio [HR], 1.04 [95% CI, 0.96-1.17]). Patients with versus without preceding PCI within 2 years had lower risk of all-cause death (HR, 0.83 [95% CI, 0.72-0.96]) but higher risk of revascularization (HR, 1.88 [95% CI, 1.50-2.36]) at 1 year. A 13-component MACE prediction model among patients with recent PCI had moderate discrimination (area under the receiver operating characteristic curve 0.73 derivation, 0.72 validation).

CONCLUSIONS

Among patients who underwent surgery, risk of MACE did not differ, but the risk of revascularization was higher and all-cause death was lower in patients with versus without recent PCI. A risk model can be used to stratify risk of surgery among patients with preceding PCI.

P2Y12 Inhibitor-Based Single Antiplatelet Therapy Versus Conventional Dual Antiplatelet Therapy After Newer-Generation Drug-Eluting Stent Implantation in Chronic and Acute Coronary Syndromes: A Systematic Review and Meta-Analysis of Randomized Clinical Trials

BACKGROUND

P2Y12 inhibitor-based single antiplatelet therapy (SAPT) after drug-eluting stent implantation reduces major bleeding without increasing the risk of major adverse cardiovascular and cerebral events compared with 12-month dual antiplatelet therapy (DAPT). The differential effects of P2Y12 inhibitor monotherapy compared with conventional DAPT in patients with chronic coronary syndromes versus acute coronary syndromes (ACS) remain uncertain.

METHODS AND RESULTS

PubMed, Embase, and Cochrane Central Register of Controlled Trials were searched for randomized controlled trials comparing oral P2Y12 inhibitor-based SAPT after ≤3 months DAPT versus 12-month DAPT after newer-generation drug-eluting stent implantation. Patients were categorized based on baseline presentation (chronic coronary syndromes versus ACS). The co-primary end points were major bleeding and major adverse cardiovascular and cerebral events, a composite of all-cause death, myocardial infarction, or ischemic stroke. A total of 43 945 (ACS, 28 360, 65%) patients from 7 randomized controlled trials were included. At a median follow-up of 12 months, P2Y12 inhibitor-based SAPT was associated with a lower risk of major bleeding (risk ratio [RR], 0.63 [95% CI, 0.48-0.82]; P<0.001) compared with 12-month DAPT. The risk of major bleeding was significantly lower among patients with ACS (RR, 0.55 [95% CI, 0.40-0.75]; P<0.001). Compared with standard DAPT, P2Y12 inhibitor-based SAPT was associated with a similar risk of major adverse cardiovascular and cerebral events (RR, 0.98 [95%CI, 0.87-1.11]; P=0.74) among patients with chronic coronary syndromes and ACS. There was no significant interaction between treatment effect and baseline presentation.

CONCLUSIONS

Compared with 12-month DAPT, P2Y12 inhibitor-based SAPT after newer-generation drug-eluting stent implantation is associated with a lower risk of major bleeding without increasing the risk of major adverse cardiovascular and cerebral events, a difference primarily driven by patients with ACS.

REGISTRATION

URL: https://www.crd.york.ac.uk/prospero/; Unique identifier: CRD42023239341.

Dual antiplatelet pre-treatment with aspirin and ticagrelor in ACS patients undergoing unplanned aortocoronary bypass surgery

BACKGROUND

Major bleedings following coronary artery bypass grafting (CABG) have significant implications on outcomes in acute coronary syndrome (ACS) patients. Owing fears of fatal bleedings in case of urgent CABG, current guidelines recommend a cessation of P2Y12 receptor antagonists (P2Y12-RA) before cardiac surgery and opt against routine pre-treatment with a P2Y12-RA before coronary angiography (CA). However, sparse information exists outside randomized trials on the frequency of urgent CABG and the consequences of inappropriately long cessation of P2Y12-RA treatment in patients presenting with ACS.

METHODS

In this observational single-center study, ACS patients presenting to an emergency department requiring a CABG were recruited consecutively during a 2-year enrolment period. Baseline characteristics, CABG-related bleedings and all-cause mortality were collected from electronical medical records and related to the timing of CABG and P2Y12-RA cessation.

RESULTS

A total of 1,502 ACS patients were included, herein 102 (6.8%) underwent urgent CABG. The majority (76.5%) received a routine P2Y12-RA pre-treatment predominantly ticagrelor in addition to low-dose aspirin before CA. 31 (30.4%) developed a CABG-related bleeding event. Bleeding probability was highest (HR: 4.77, 95%CI 2.20-10.37, p = 0.0001) when CABG was performed within 24 h after administration of dual anti-platelet therapy (DAPT). Despite high utilization rates of DAPT pre-treatment and high prevalence of CABG-related major bleedings, no fatal bleedings occurred.

CONCLUSIONS

Need of urgent CABG in ACS is infrequent and does not result in an excess of mortality. However, cessation of ticagrelor for at least 48 h before CABG is recommended to minimize rates of CABG-related bleedings.

Scutellarin ameliorates ischemia/reperfusion-mediated endothelial dysfunction by upregulating cathepsin D expression to rescue autophagy-lysosomal function

Background

Endothelial dysfunction-induced microcirculation impairment and the no-reflow phenomenon are the leading causes of cardiac ischemia/reperfusion (I/R) injury. There is an urgent need to elucidate the underlying mechanism of I/R-mediated endothelial dysfunction and to identify effective drugs for treatment. Scutellarin (SCU), a flavonoid compound, has been extensively studied because of its various pharmacological properties, including its potent protective effects on the cardiovascular system. However, the anti-endothelial dysfunction efficacy and mechanisms of action of SCU have not been investigated.

Approach and results

An in vivo I/R injury model was established using coronary artery ligation and release. An oxygen-glucose deprivation/oxygen-glucose resupply (OGD/OGR) approach was used to establish an in vitro I/R injury model. We evaluated the effects of SCU on endothelial dysfunction under I/R conditions, both in vivo and in vitro. SCU pretreatment promoted vasodilation and reperfusion of blood flow, inhibited myocardial injury and infarction, and improved cardiac function in I/R rats. Additionally, SCU inhibited cell membrane damage, reactive oxygen species (ROS) accumulation, inflammation, nitric oxide (NO) reduction, endothelin 1 (ET-1) elevation and increase in the expression levels of vascular endothelial growth factor (VEGF) and von willebrand factor (vWF) in endothelial cells. Mechanistically, SCU rescued the lysosomal flow and autophagic flux disrupted by I/R through upregulating cathepsin D (CTSD) levels. Knockdown of CTSD or treatment with the CTSD inhibitor pepstatin A (P.A) abrogated the protective effects of SCU on endothelial cells under I/R conditions.

Conclusion

We demonstrated that SCU, via upregulation of CTSD levels in endothelial cells, rescued autophagy-lysosomal function and alleviated I/R-mediated endothelial dysfunction. Thus, SCU is a potential therapeutic drug for the prevention and treatment of cardiac I/R injury.

Characteristics and Outcomes of PCI Among Patients Ineligible for Surgical Revascularization in the Veterans Affairs Healthcare System

BACKGROUND

Ineligibility for surgical revascularization is increasingly prevalent and associated with increased mortality after percutaneous coronary intervention (PCI). High-quality, contemporary, multicenter data regarding clinical outcomes after PCI is scarce and poses a barrier to clinical decision-making for surgically ineligible patients. The aim of this study was to describe and compare the clinical characteristics, institutional variation, and longitudinal outcomes of PCI among surgically eligible and ineligible patients in the Veterans Affairs Healthcare System.

METHODS

Patients with left main and/or multivessel coronary artery disease undergoing index PCI between October 1, 2017 and September 30, 2022 were identified and the prevalence of surgical ineligibility determined by review of the electronic medical record. The association between surgical ineligibility and mortality and major adverse cardiovascular events (MACE; death, myocardial infarction, repeat revascularization, and stroke) was assessed.

RESULTS

A total of 6192 patients with left main and/or multivessel coronary artery disease (842 surgically ineligible and 5350 surgically eligible) underwent PCI during the study period. After adjustment, surgical ineligibility was associated with a significantly decreased time to mortality (time ratio, 0.801 [95% CI, 0.662-0.970]) over a median 1045-day (interquartile range, 583-1600) follow-up period, though not associated with composite MACE (time ratio, 0.859 [95% CI, 0.685-1.078]). After adjustment for target lesion characteristics and procedural complexity, the association between surgical ineligibility and mortality was attenuated (time ratio, 0.842 [95% CI, 0.688-1.030]).

CONCLUSIONS

Ineligibility for surgical revascularization was associated with increased risk of long-term mortality after PCI. The risk of adverse outcomes after PCI, however, was similar among surgically eligible and ineligible patients after adjusting for measured comorbidities, coronary anatomic features, and procedural complexity.

Rivaroxaban versus Enoxaparin in Patients with Radial Artery Occlusion after Transradial Coronary Catheterization: A Pilot Randomization Trial

The radial artery is currently the main vascular access site for cardiac catheterization. Radial artery occlusion (RAO), although a relatively silent complication, raises concerns because of its potential impact on future procedures. This pilot randomized controlled trial compared the efficacy and safety of two anticoagulation regimens-subcutaneous enoxaparin and oral rivaroxaban-in resolving symptomatic ultrasound-confirmed RAO in 40 patients (median age 55 years [interquartile range, 48-64], including 26 female patients [70.3%]) who underwent diagnostic cardiac catheterization without requiring dual antiplatelet therapy. Thirty-seven patients completed the 28-day ultrasound-based follow-up, demonstrating comparable complete or partial resolution rates between rivaroxaban (16 of 20 patients [80.0%]) and enoxaparin (14 of 17 patients [82.3%]), with an odds ratio of 0.85 (95% confidence interval: 0.16 to 4.50). No major bleeding events occurred during the 28-day follow-up period. While rivaroxaban shows potential in resolving RAO, larger studies are necessary to validate these findings and evaluate the long-term outcomes.

Case Report: Delayed diagnosis: a case of left main coronary artery spasm

Left main coronary artery (LMCA) spasm is an exceedingly rare but potentially fatal condition. We present a case of severe stenosis of LMCA found by coronary angiography (CAG) due to recurrent chest pain, and subsequently received coronary artery bypass grafting (CABG). Nine years later, the patient was readmitted to the hospital because of precordial discomfort. During hospitalization, CAG was performed once again and showed no significant stenosis in the LMCA, leading to the diagnosis of LMCA spasm. This case emphasizes to interventional cardiologists the critical need to consider the possibility of LMCA spasm when diagnosing LMCA lesions. It highlights the importance of thorough and proactive pretreatment and comprehensive clinical judgment to minimize the risk of misdiagnosis.

Efficacy and safety of nicorandil for prevention of contrast-induced nephropathy in patients undergoing coronary procedures: a systematic review and meta-analysis

BACKGROUND

Contrast-induced nephropathy (CIN) is a potentially serious complication of intravenous or intra-arterial contrast administration during angiographic procedures that results in renal dysfunction. CIN can increase the risk of mortality by three-fold. This meta-analysis assesses the efficacy and safety of nicorandil for the prevention of CIN in patients undergoing percutaneous coronary intervention (PCI) or coronary angiography (CAG).

METHODS

Cochrane Central Register of Controlled Trials, MEDLINE, Embase, and ClinicalTrials.gov were used to perform a thorough literature search from their inception to July 2024. Twelve randomized controlled trials (RCTs) were included. A random-effects meta-analysis was performed on RevMan and pooled estimates were presented as forest plots. The Mantel-Haenszel method was used for dichotomous outcomes and risk ratios (RRs) were calculated along with 95% confidence intervals (95% CI).

RESULTS

This meta-analysis included 2787 participants (nicorandil: 1418, control: 1394). The use of nicorandil was protective against CIN (RR 0.38, 95% CI 0.29-0.50). There was no significant difference in major adverse events between the groups (RR 0.77, 95% CI 0.52-1.13, p = 0.18). Similarly, the use of nicorandil did not affect the risk of developing stroke (RR 1.05, 95% CI: 0.38-2.95), myocardial infarction (RR 0.90, 95% CI: 0.56-1.43), heart failure (RR 0.81, 95% CI: 0.39-1.68), cardiac death (RR 0.90, 95% CI: 0.28-2.88) and dialysis (RR 0.70, 95% CI: 0.11-4.44).

CONCLUSION

This meta-analysis concludes that nicorandil reduces CIN incidence after PCI or CAG without significantly increasing major adverse events. However, further well-designed, large-scale RCTs are needed to strengthen the practical relevance before routine clinical use.

Psychosocial interventions for smoking cessation in people with coronary heart disease

OBJECTIVES

This is a protocol for a Cochrane Review (intervention). The objectives are as follows: Primary objective To examine the benefits and harms of different types of psychosocial interventions for smoking cessation in people with CHD. Secondary objectives To examine the benefits and harms of psychosocial interventions aimed solely at smoking cessation compared with multi-risk factor interventions for smoking cessation in people with CHD. To examine the benefits and harms of brief (duration of < one month) compared to extended (duration of ≥ one month) psychosocial interventions for smoking cessation in people with CHD. To explore whether using a validated biochemical assessment versus a self-report of abstinence moderates the effectiveness of smoking cessation interventions in people with CHD. To assess the equity of psychosocial interventions for smoking cessation in people with CHD.

Lesion-specific coronary artery calcium score to predict stent underexpansion

Background

Previous intracoronary imaging studies have shown that coronary artery calcium (CAC) is an independent risk factor of stent underexpansion; however, limited preintervention assessments of CAC have been performed using noninvasive methods. We aimed to determine the association between lesion-specific CAC score and stent underexpansion.

Methods

In this retrospective observational study, we included 416 lesions from 359 patients who underwent intravascular ultrasound (IVUS)-guided stent implantation. CAC of each lesion was quantified using the Agatston method derived from either nongated noncontrast chest CT (NCCT) or electrocardiogram-gated coronary CT angiography (CCTA). The primary endpoint was stent underexpansion defined as minimum stent area of <80% of the average reference lumen area.

Results

Overall, stent underexpansion occurred in 144 (34.6%) of 416 lesions. Lesion-specific CAC score was significantly negatively correlated with the stent expansion rate (in NCCT cohort, r = 0.8113, P < 0.05; in CCTA cohort, r = 0.8024, P < 0.05). The optimal cutoff values of lesion-specific CAC score to predict stent underexpansion were >200 in both NCCT (sensitivity, 91.4%; specificity, 66.8%) and CCTA (sensitivity, 84.6%; specificity, 64.3%) cohort, which were associated with 24.94-fold increased risk of stent underexpansion in NCCT cohort and 13.56-fold increased risk of stent underexpansion in CCTA cohort.

Conclusions

In this study, we found that lesion-specific CAC scores in both NCCT and CCTA cohorts were significantly independently associated with an increased risk of stent underexpansion, and the cutoff value to predict stent underexpansion was >200.

Mechanical circulatory support for complex, high-risk percutaneous coronary intervention

The evidence base evaluating the use of mechanical circulatory support (MCS) devices in complex, high-risk percutaneous coronary intervention is evolving from a small number of randomised clinical trials to incorporate an amassing body of real-world data. Due to both the growing incidence of the procedures and the limitations of the evidence, there is wide variability in the use of MCS, and the benefits are actively debated. The goal of this review is to perform an integrated analysis of randomised and non-randomised studies which have informed clinical and regulatory decision-making in contemporary clinical practice. In addition, we describe forthcoming studies that have been specifically designed to advance the field and resolve ongoing controversies that remain unanswered for this complex, high-risk patient population.

Clinical Outcomes and Safety Profiles of Generic Versus Brand-Name Clopidogrel in Patients Following Coronary Artery Stent Placement

Coronary artery disease remains a significant global health issue and is a leading cause of mortality. Dual antiplatelet therapy, including clopidogrel, is essential for preventing stent thrombosis after coronary artery stenting. This study assessed the comparative efficacy and safety of generic versus brand-name clopidogrel in a large Taiwanese cohort. A retrospective cohort study was conducted using the National Health Insurance database, identifying patients who underwent coronary stenting and received either generic or brand-name clopidogrel between January 1, 2008, and December 31, 2021. Propensity score matching was employed to balance baseline characteristics. The primary efficacy outcome was a composite of myocardial infarction, ischemic stroke, or cardiovascular death over a two-year follow-up. The primary safety outcome was major bleeding requiring hospitalization. A total of 211,509 patients were included, of which 2686 received generic clopidogrel and 208,823 received brand-name clopidogrel. After matching, 2686 patients from each group were analyzed. The hazard ratio for the primary efficacy outcome was 0.92 (95% confidence interval: 0.78-1.10), indicating no significant difference between the two groups. The subdistribution hazard ratio for the primary safety outcome was 1.06 (95% confidence interval: 0.84-1.33), suggesting no significant difference in bleeding risk. Subgroup analyses showed consistent results across various patient demographics and clinical conditions. In conclusion, among patients undergoing coronary stenting, the risks of ischemic and bleeding events were comparable between those receiving generic and brand-name clopidogrel.

Role of C/EBP Homologous Protein in Vascular Stenosis After Carotid Artery Injury

The study aims to explore the fluctuating expression of C/EBP Homologous Protein (CHOP) following rat carotid artery injury and its central role in vascular stenosis. Using in vivo rat carotid artery injury models and in vitro ischemia and hypoxia cell models employing human aortic endothelial cells (HAECs) and vascular smooth muscle cells (T/G HA-VSMCs), a comprehensive investigative framework was established. Histological analysis confirmed intimal hyperplasia in rat models. CHOP expression in vascular tissues was assessed using Western blot and immunohistochemical staining, and its presence in HAECs and T/G HA-VSMCs was determined through RT-PCR and Western blot. The study evaluated HAEC apoptosis, inflammatory cytokine secretion, cell proliferation, and T/G HA-VSMCs migration through Western blot, ELISA, CCK8, and Transwell migration assays. The rat carotid artery injury model revealed substantial fibrous plaque formation and vascular stenosis, resulting in an increased intimal area and plaque-to-lumen area ratio. Notably, CHOP is markedly elevated in vessels of the carotid artery injury model compared to normal vessels. Atorvastatin effectively mitigated vascular stenosis and suppresses CHOP protein expression. In HAECs, ischemia and hypoxia-induced CHOP upregulation, along with heightened TNFα, IL-6, caspase3, and caspase8 levels, while reducing cell proliferation. Atorvastatin demonstrated a dose-dependent suppression of CHOP expression in HAECs. Downregulation of CHOP or atorvastatin treatment led to reduced IL-6 and TNFα secretion, coupled with augmented cell proliferation. Similarly, ischemia and hypoxia conditions increased CHOP expression in T/G HA-VSMCs, which was concentration-dependently inhibited by atorvastatin. Furthermore, significantly increased MMP-9 and MMP-2 concentrations in the cell culture supernatant correlated with enhanced T/G HA-VSMCs migration. However, interventions targeting CHOP downregulation and atorvastatin usage curtailed MMP-9 and MMP-2 secretion and suppressed cell migration. In conclusion, CHOP plays a crucial role in endothelial injury, proliferation, and VSMCs migration during carotid artery injury, serving as a pivotal regulator in post-injury fibrous plaque formation and vascular remodeling. Statins emerge as protectors of endothelial cells, restraining VSMCs migration by modulating CHOP expression.

Clinical Outcomes Following Optical Coherence Tomographic Versus Intravascular Ultrasound-Guided Percutaneous Coronary Intervention: A Meta-Analysis of Randomized Controlled Trials

BACKGROUND

Optical coherence tomography (OCT) and intravascular ultrasound (IVUS) are adjunctive intracoronary imaging modalities used to optimize coronary stent implantation. However, the impact of OCT versus IVUS on clinical outcomes and periprocedural complications is unclear.

AIMS

To perform a meta-analysis of all vetted randomized controlled trials comparing OCT-guided versus IVUS-guided percutaneous coronary intervention.

METHODS

We queried MEDLINE, Cochrane Library, Scopus, and clinicalTrials.gov databases from their commencement to February 2024 for all randomized controlled trials that compared OCT-guided versus IVUS-guided percutaneous coronary interventions. The primary endpoint was major adverse periprocedural events (MAPE), a composite of stent thrombosis (ST), distal embolization (DE), and distal edge dissection (DED) at 30 days. The secondary endpoints included ST, DE, DED, major adverse cardiac events (MACE)-(a composite of cardiac death, target vessel myocardial infarction TVMI], and target vessel revascularization [TVR]), all-cause mortality, cardiac death, TVMI, TVR, and nonfatal stroke at 1 year. The odds ratio (OR) with a 95% confidence interval (CI) was analyzed using a random-effect model.

RESULTS

Seven randomized controlled trials were included in the analysis, and 4446 patients were enrolled. OCT was associated with lower MAPE (OR: 0.65, CI: 0.47-0.91, p = 0.01) compared to IVUS. ST, DE, and DED were similar between OCT and IVUS at 30 days. There were no significant differences in MACE (OR: 0.86, CI: 0.64-1.16, p = 0.32), all-cause mortality (OR: 0.83, CI: 0.42-1.66, p = 0.60), Cardiac death (OR:0.62, CI: 0.20-1.89, p = 0.40), TVMI (OR: 0.69, CI: 0.33-1.46, p = 0.33), TVR, (OR: 1.09, CI: 0.70-1.71, p = 0.70), and Nonfatal stroke (OR: 1.82, CI: 0.67-4.95, p = 0.24) 1 year following the index procedure.

CONCLUSION

Optical coherence tomographic-guided PCI was associated with lower MAPE, defined as a composite of ST, DE, and DED, compared to IVUS-guided PCI at 30 days of the index procedure. However, there was no difference in overall MACE, TVMI, TVR, and nonfatal stroke at 1 year.

Revascularization of Chronic Total Occlusions vs. Planned Complex Percutaneous Coronary Intervention: Long-Term Outcomes and Mortality

Introduction: The number of chronic total occlusion (CTO) revascularization procedures has continuously increased, obtaining better results in recent years. However, there are few data regarding long-term outcomes and no comparisons to planned complex non-CTO percutaneous coronary intervention (PCI). Methods: We included all patients undergoing planned complex PCI. Our main objective was to compare a combined endpoint of all-cause death, myocardial infarction, and target vessel revascularization at the long-term follow-up of CTO PCI versus planned complex non-CTO PCI. We compared the groups using multivariable Cox regression and performed a propensity score matching analysis to control the baseline characteristics. We repeated the analysis for the separate components of the primary endpoint. Results: From January 2018 to June 2023, 1394 complex coronary PCIs were performed at our center. After excluding 393 non-planned cases, 201 CTO PCIs and 800 non-CTO PCIs were included. The mean follow-up was 2.5 ± 1.5 years. The composite endpoint occurred in 23 (11.6%) CTO PCIs and 219 (28.2%) planned non-CTO PCIs. The multivariable Cox regression using the CTO group as the reference showed a lower risk for the primary outcome (HR: 0.59; 95% CI 0.37-0.95; p = 0.031). After matching, a total of 195 adequately balanced pairs were obtained. The CTO group presented a lower risk for the primary combined outcome (HR: 0.46; 95% CI 0.27-0.76; p = 0.003). Conclusions: In patients undergoing planned complex PCI, those in the CTO group presented a reduced risk of all-cause death, myocardial infarction, and target vessel revascularization at the end of the follow-up.

Mechanical Circulatory Support in Patients Without Cardiogenic Shock Undergoing Percutaneous Coronary Intervention

BACKGROUND

The use of mechanical circulatory support devices for high-risk percutaneous coronary intervention (PCI) has increased over the past decade despite limited data of benefit. We sought to examine the association between intravascular microaxial left ventricular assist device (LVAD) versus intra-aortic balloon pump use in patients without cardiogenic shock (CS) undergoing PCI.

METHODS AND RESULTS

This retrospective study analyzed claims data from a large, insured population who underwent PCI without CS from April 1, 2016 to July 31, 2022. Using inverse probability treatment weighting, we assessed for the association between device type and clinical outcomes. The primary outcome was all-cause mortality. Secondary outcomes included stroke, bleeding, incident dialysis, repeat revascularization, and total health care costs during the index admission and at 30 days. We identified 2879 patients without CS who underwent PCI with either an intra-aortic balloon pump or microaxial LVAD. The mean±SD age was 68.2±12.5 years, and 27% (n=764) were women. After propensity weighting, intravascular LVAD use was not associated with a significant difference in either in-hospital (odds ratio [OR] 1.30 [95% CI, 0.88-1.91]; P=0.19) or 30-day mortality (OR, 1.19 [95% CI, 0.84-1.69]; P=0.33) compared with intra-aortic balloon pump use. Compared with those receiving an intra-aortic balloon pump, the mean total costs for the index admission ($96 716 versus $71 892; P<0.001) and at 30 days (+$16 671 [95% CI, $6639-$28 103]; P=0.001) were significantly higher in those receiving an intravascular LVAD. There was no significant association between device type and stroke, bleeding, incident dialysis, and repeat revascularization at any time point (all P>0.05).

CONCLUSIONS

In patients without CS undergoing PCI, intravascular LVAD use was associated with higher costs but not associated with lower mortality. Randomized data are needed to improve device selection for patients without CS undergoing PCI.

Acupuncture Dosage and Its Correlation with Effectiveness in Patients with Chronic Stable Angina: A Systematic Review and Meta-Analysis of Randomized Controlled Trial

Objective

This systematic review aimed to compare the efficacy of various acupuncture dosages for Chronic Stable Angina (CSA) using randomized controlled trials (RCTs), addressing the unclear relationship between dosage and effectiveness despite acupuncture's potential.

Methods

We searched eight bibliographic databases from inception to October 31, 2024, evaluating RCTs comparing acupuncture to placebo or standard care for CSA patients, focusing on angina attack frequency as the primary outcome. Studies were categorized into high (HDG), moderate (MDG), and low (LDG) dosage groups based on acupuncture characteristics: the number of acupoints, total sessions, frequency per week, and the need for "Deqi".

Results

Of the 807 citations screened, 16 studies (1240 patients) were included: 3 studies in LDG, 10 in MDG, and 3 in HDG. Acupuncture significantly reduced angina attacks compared to placebo (SMD, -0.51; 95% CI [-0.77, -0.25], P = 0.0001, I 2=62%), and standard care (SMD, -1.25, 95% CI [-1.89, -0.61], P = 0.00001, I2 =92%) without increasing adverse events. MDG showed a notable difference in reducing angina attacks (SMD, -0.60, 95% CI [-0.91, -0.29], P = 0.001, I2 =60%) while LDG and HDG did not. There is no difference in adverse events between groups. The evidence quality ranged from very low to moderate, and the results should be cautiously applied.

Conclusion

Acupuncture therapy effectively and safely alleviates CSA symptoms. Moderate dosage demonstrated the potential for better effects in reducing symptoms, suggesting optimal dosage considerations for future treatments.

Prospero Registration Number

CRD42022321547.

The effect of NLRP3 inflammasome on cardiovascular prognosis in patients with acute coronary syndrome

The NOD‑like receptor protein domain associated protein 3 (NLRP3) inflammasome is critical in inflammatory responses and may be a valuable prognostic biomarker in acute coronary syndrome (ACS). We aimed to investigate the association between NLRP3 inflammasome levels and short-term outcomes in patients with ACS. We enrolled 295 patients with ACS who were monitored for 6 months for major adverse cardiovascular events (MACEs). The NLRP3 inflammasome was quantified using enzyme-linked immunosorbent assays, with the Gensini score used to assess disease severity. A Cox regression model evaluated whether NLRP3 inflammasome levels were independent predictors of MACEs. Spearman correlation analysis demonstrated a significant positive correlation between NLRP3 inflammasome levels and the Gensini score (r = 0.55, p < 0.001). Plasma NLRP3 inflammasome levels were significantly higher in the MACEs group (8.48 ng/mL) compared with the no-MACEs group (3.48 ng/mL) (p < 0.001). Multivariate Cox regression identified NLRP3 inflammasome content as an independent risk factor for MACEs (hazard ratio 1.104, p = 0.001; area under the curve: 0.780 [95% confidence interval 0.721-0.840], p < 0.001). Elevated plasma NLRP3 inflammasome levels correlated with ACS severity and were associated with poorer short-term outcomes in patients with ACS.

Prognosis after switching to electronic cigarettes following percutaneous coronary intervention: a Korean nationwide study

BACKGROUND AND AIMS

Despite the increasing popularity of electronic cigarettes (E-cigarettes), the prognostic impact of switching to E-cigarettes in smokers with coronary artery disease who have undergone percutaneous coronary intervention (PCI) remains unclear.

METHODS

Using a nationwide cohort from the Korean National Health Insurance database, 17 973 adults (≥20 years) identified as smokers (based on a health screening examination within 3 years before PCI) who underwent health screening within 3 years after PCI were enrolled to determine changes in smoking habits. Patients were classified as continued combustible cigarette users, successful quitters, or switchers to E-cigarettes. The group switching to E-cigarettes was further divided into dual users (using both combustible and E-cigarettes) and those exclusively using E-cigarettes. Primary outcomes included major adverse cardiac events (MACEs), a composite of all-cause death, spontaneous myocardial infarction, and repeat revascularization.

RESULTS

Among the total population, 8951 patients (49.8%) continued using combustible cigarettes, 1694 (9.4%) were switched to E-cigarettes, and 7328 (40.7%) successfully quit smoking after PCI. During a median follow-up of 2.4 years, the cumulative incidence of MACE was lower among E-cigarette switchers (10%) or quitters (13.4%) than among continued combustible cigarette users (17%). When continued combustible cigarette users were used as the reference, the multivariable-adjusted hazard ratios with 95% confidence intervals for MACE were 0.82 (0.69-0.98) for switchers to E-cigarettes and 0.87 (0.79-0.96) for successful quitters. Compared with dual users, entirely switching to E-cigarettes was associated with a significantly lower MACE risk (hazard ratio 0.71; 95% confidence interval 0.51-0.99).

CONCLUSIONS

Among smokers who underwent PCI for coronary artery disease, switching to E-cigarette use (particularly complete transition) or quitting smoking was associated with reduced MACE risk than with continued combustible cigarette use.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov NCT06338761.

Coronary Revascularization Guided With Fractional Flow Reserve or Instantaneous Wave-Free Ratio: A 5-Year Follow-Up of the DEFINE FLAIR Randomized Clinical Trial

Importance

The differences between the use of fractional flow reserve (FFR) or instantaneous wave-free ratio (iFR) in the long term are unknown.

Objective

To compare long-term outcomes of iFR- and FFR-based strategies to guide revascularization.

Design, Setting, and Participants

The DEFINE-FLAIR multicenter study randomized patients with coronary artery disease to use either iFR or FFR as a pressure index to guide revascularization. Patients from 5 continents with coronary artery disease and angiographically intermediate severity stenoses who underwent hemodynamic interrogation with pressure wires were included. These data were analyzed from March, 13, 2014, through April, 27, 2021.

MAIN OUTCOME MEASURES

Five-year major adverse cardiac events (MACE) (a composite of all-cause death, nonfatal myocardial infarction, and unplanned revascularization), as well as the individual components of the combined end point.

Results

At 5 years of follow-up, no significant differences were found between the iFR (mean age [SD], 65.5 [10.8] years; 962 male [77.5%]) and FFR (mean age [SD], 65.2 [10.6] years; 929 male [74.3%]) groups in terms of MACE (21.1% vs 18.4%, respectively; hazard ratio [HR], 1.18; 95% CI, 0.99-1.42; P = .06). While all-cause death was higher among patients randomized to iFR, it was not driven by myocardial infarction (6.3% vs 6.2% in the FFR study arm; HR, 1.01; 95% CI, 0.74-1.38; P = .94) or unplanned revascularization (11.9% vs 12.2% in the FFR group; HR, 0.98; 95% CI, 0.78-1.23; P = .87). Furthermore, patients in whom revascularization was deferred on the basis of iFR or FFR had similar MACE in both study arms (17.9% in the iFR group vs 17.5% in the FFR group; HR, 1.03; 95% CI, 0.79-1.35; P = .80) with similar rates of the components of MACE, including all-cause death. On the contrary, in patients who underwent revascularization after physiologic interrogation, the incidence of MACE was higher in the iFR group (24.6%) compared with the FFR group (19.2%) (HR, 1.36; 95% CI, 1.07-1.72; P = .01).

Conclusions and relevance

At 5-year follow up, an iFR based-strategy was not statistically different than an FFR strategy to guide revascularization in terms of MACE, nonfatal myocardial infarction, and unplanned revascularization.

Trial Registration

ClinicalTrials.gov Identifier: NCT02053038.

Standardizing plaque impact on overall coronary hemodynamics using a binomial equation based on the equivalent energy loss

This study proposes a novel method for evaluating the risk of adverse events (AE) in patients with coronary stenosis based on the morphology and hemodynamics along a whole coronary artery. Twenty-eight specific coronary artery tree models with different stenotic degrees are established from the CCTA images and divided into AE group and Non-AE group. Pressures are obtained by computational fluid dynamics method. The left anterior descending branches are divided equidistantly along the centerline. The characteristic diameters of each segment are measured and normalized to standard the patient-specific coronary arteries as characteristic straight pipes with variable cross-sections. Based on the energy loss theory, the normalized characteristic diameters ( [Formula: see text] ) and pressure drops (Δpi) of each segment are fitted to a binomial equation. The differences of binomial coefficients between the two groups are compared. The results show that: [Formula: see text] changes suddenly in the lesions part and Δpi fluctuates in the posterior half of lesions part and its upstream and downstream. There is a significant difference in the ratio of two binomial equation coefficients, which represents the combination of local resistance coefficient, length, flow rate and maximum characteristic diameter of the standard pipe (0.93 ± 0.16 vs. 1.42 ± 0.58, p = 0.0003). This method emphasizes the influences of stenosis on the whole coronary artery, and reflects the cardiac function requirements of the stenotic coronary artery from the patient itself. The ratio of two binomial equation coefficients can supplement the information obtained by existing detection methods and may help evaluate the risk of AEs.

Revisiting the Efficacy and Safety of Bivalirudin in Patients With ST-Segment Elevation Myocardial Infarction Undergoing Percutaneous Coronary Intervention: Insights From a Mixed Treatment Comparison Meta-Analysis of Randomized Trials

BACKGROUND

Randomized trials of bivalirudin in patients with ST elevation myocardial infarction (STEMI) have yielded heterogeneous results.

AIMS

Our aim was to evaluate the efficacy and safety of four antithrombin regimens-unfractionated heparin (UFH), bivalirudin (stopped soon after percutaneous coronary intervention [PCI]), extended bivalirudin (continued for a few hours after PCI), and combined UFH and a Gp2b3a inhibitors (GPI) in patients who present with STEMI.

METHODS

A PubMed, EMBASE, and clinicaltrials.gov databases were searched for randomized clinical trials (RCTs) of the above antithrombin in patients with STEMI. The primary outcome was net adverse cardiovascular events (NACE). The primary ischemic endpoint was major adverse cardiovascular events (MACE), and the primary safety endpoint was major bleeding, and other endpoints included all-cause mortality and stent thrombosis. The primary analysis compared the effect of these antithrombin regimens in reference to UFH using a mixed treatment comparison meta-analysis.

RESULTS

In the 14 RCTs evaluating 25,415 patients with STEMI, when compared to UFH monotherapy, extended bivalirudin lowered NACE (OR = 0.71 with 95% CI: 0.53-0.96; moderate level of confidence) driven by a significant decrease in major bleeding (OR = 0.42 with 95% CI: 0.26-0.68; high level of confidence) without any significant difference in MACE or all-cause mortality. When compared with UFH monotherapy, UFH+GPI reduced risk of MACE (OR = 0.76 with 95% CI: 0.60-0.97; high level of confidence) but at the expense of an increase in major bleeding (OR = 1.48 with 95% CI: 1.11-1.98; high level of confidence) with no difference in NACE or all-cause mortality. For major bleeding, extended bivalirudin infusion ranked #1, bivalirudin ranked #2, UFH monotherapy ranked #3, and combined UFH and GPI ranked #4. For NACE, extended bivalirudin infusion ranked #1, bivalirudin ranked #2, combined UFH and GPI ranked #3, and UFH monotherapy ranked #4. Cluster plots for MACE and major bleeding demonstrated that extended bivalirudin had the best balance for efficacy and safety.

CONCLUSIONS

In patients undergoing PCI for STEMI, extended bivalirudin offers the best balance for primary ischemic (MACE) and safety (major bleeding) outcomes.

Management of Stent Underexpansion and Aorto-ostial Lesions

Stent underexpansion (SU) and aorto-ostial lesions (AOL) are challenging conditions commonly faced during clinical practice in the setting of percutaneous coronary interventions. Compared to other interventional settings, both SU and AOL are associated with an increased risk of immediate and late events following percutaneous coronary intervention. Several specific strategies including the systematic use of intracoronary imaging and dedicated techniques for lesions' preparation and calcium debulking have been described. This narrative review summarises the currently available options for the diagnosis and treatment of both SU and AOL, highlighting the potential benefits and limits of each technique in these specific settings.

Triple-Vessel Spontaneous Coronary Artery Dissection Managed Conservatively

The management of spontaneous coronary artery dissection (SCAD) presents challenges and uncertainties. We present a case of a 54-year-old woman who developed SCAD in the three primary coronary artery territories including the distal left anterior descending artery (LAD), a diagonal branch, the first and second obtuse marginals (OMs), and the midright coronary artery (RCA). She was managed conservatively without procedural intervention, and follow-up coronary angiography demonstrated complete recovery.

Fractional flow reserve-guided complete revascularization versus culprit-only percutaneous coronary intervention in patients with myocardial infarction: A meta-analysis of randomized controlled trials

INTRODUCTION

The optimal revascularization strategy for patients with myocardial infarction (MI) and multivessel coronary artery disease (CAD) remains an area of research and debate. Fractional flow reserve (FFR)-guided complete revascularization (CR) by percutaneous coronary intervention (PCI) has emerged as an alternative to traditional culprit-only PCI.

OBJECTIVE

To investigate the outcomes of FFR-guided CR versus culprit-only PCI in patients with MI and multivessel CAD.

METHODS

We systematically searched PubMed, Scopus and Cochrane Central databases for randomized controlled trials (RCTs) comparing FFR-guided CR versus culprit-only PCI in MI patients with multivessel CAD. Outcomes included a composite of all-cause death, MI, stroke and repeat revascularization, these individual outcomes, cardiac death, stent thrombosis (definite or probable), and contrast-induced acute kidney injury (CIAKI). Random effects models were used to generate risk ratios (RRs) with 95 % confidence intervals (CIs).

RESULT

The search identified 5 RCTs including 4618 patients with a median follow-up duration of 3 years. Compared with culprit-only PCI, FFR-guided CR was associated with less composite adverse events (RR 0.73; 95%CI 0.57-0.92; p = 0.009), cardiac death (RR 0.73; 95%CI 0.55-0.97; p = 0.03), and repeat revascularization (RR 0.61; 95%CI 0.44-0.84; p = 0.003). Both strategies were similar in terms of all-cause death, MI, stroke, stent thrombosis, and CIAKI.

CONCLUSION

FFR-guided complete revascularization appears to be superior to culprit-only PCI in reducing composite adverse events, cardiac death, and the need for repeat revascularization in patients with MI and multivessel CAD without a significant impact on recurrent myocardial infarction rates.

SOCIAL MEDIA ABSTRACT

4618-patient meta-analysis: in MI w/ multivessel #CAD, #FFR-guided complete revascularization yields less composite adverse events, cardiac death & repeat revascularization than culprit-only #PCI.

Complete or incomplete revascularization in patients with left main culprit lesion acute myocardial infarction with multivessel disease: a retrospective observational study

BACKGROUND

Complete revascularization has demonstrated better outcomes in patients with acute myocardial infarction (AMI) and multivessel disease. However, in the case of left main (LM) culprit lesion AMI with multivessel disease, there is limited evidence to suggest that complete revascularization is better.

METHODS

We reviewed 16,831 patients in the Korea Acute Myocardial Infarction Registry who were treated from July 2016 to June 2020, and 399 patients were enrolled with LM culprit lesion AMI treated with percutaneous coronary intervention. We categorized the patients as those treated with complete revascularization (n=295) or incomplete revascularization (n=104). The study endpoint was major adverse cardiac and cerebrovascular events (MACCE), a composite of all-cause death, myocardial infarction, ischemia-driven revascularization, stent thrombosis, and stroke. We performed propensity score matching (PSM) and analyzed the incidence of MACCE at 1 year.

RESULTS

After PSM, the two groups were well balanced. There was no significant difference between the two groups in MACCE at 1 year (12.1% vs. 15.2%; hazard ratio, 1.28; 95% confidence interval, 0.60-2.74; p=0.524) after PSM. The components of MACCE and major bleeding were also not significantly different.

CONCLUSION

There was no significant difference in clinical outcomes between the groups treated with complete or incomplete revascularization for LM culprit lesion AMI with multivessel disease.

Reduced-dose of bivalirudin (without the post-procedure infusion) in patients with acute coronary syndrome undergoing elective percutaneous coronary intervention

INTRODUCTION

In clinical practice, the dose of bivalirudin may not be fully applicable to the Chinese population. Therefore, this study aimed to explore the efficacy and safety of a reduced dose (80% of the recommended dose) of bivalirudin without post-procedure infusion for 3-4 h in patients with acute coronary syndrome (ACS) undergoing elective percutaneous coronary intervention (PCI).

METHODS

This was a single-center, retrospective study. Patients who met the inclusion criteria and no exclusion criteria were divided into reduced-dose and recommended-dose groups for analysis. Confounders were corrected using propensity score matching. The incidence of net adverse clinical events (NACE), major adverse cardiovascular events (MACE), and Bleeding Academic Research Consortium (BARC) type 2-5 bleeding events were observed 30 days postoperatively.

RESULTS

In total, 1,590 patients (795 per group) were obtained after propensity score matching. The results after propensity score matching were as follows: The activated clotting time (ACT) after 5 min in the reduced-dose group was 349.37 ± 47.59 s, which was statistically lower than that in the recommended-dose group, 353.12 ± 44.98 s (P = 0.024). There was no significant difference in the proportion of ACT values of ≥ 250 s after 5 min between the two groups (P > 0.05). There were no significant differences in NACE, MACE, and BARC type 2-5 bleeding events between the two groups (5.0% vs. 4.5%, P = 0.638; 0.0% vs. 0.1%, P = 1.000; 0.3% vs. 0.5%, P = 0.687). There were no statistically significant differences in cumulative NACE and cumulative bleeding events between the two groups at 30 days (P = 0.635 and P = 0.716, respectively).

CONCLUSION

In patients with UA and NSTEMI undergoing elective PCI, 80% of the recommended dose of bivalirudin without post-procedure infusion can be used for anticoagulation without increasing the risk of thrombosis and bleeding.

Update on Diagnosis and Management of Kawasaki Disease: A Scientific Statement From the American Heart Association

Kawasaki disease (KD), an acute self-limited febrile illness that primarily affects children <5 years old, is the leading cause of acquired heart disease in developed countries, with the potential of leading to coronary artery dilation and coronary artery aneurysms in 25% of untreated patients. This update summarizes relevant clinical data published since the 2017 American Heart Association scientific statement on KD related to diagnosis, cardiac imaging in acute KD treatment, and long-term management. Criteria defining North American patients at high risk for developing coronary artery aneurysms who may benefit from more intensive initial treatment have been published. Advances in cardiovascular imaging have improved the ability to identify coronary artery stenosis in patients with KD, yet knowledge gaps remain regarding optimal frequency of serial imaging and the best imaging modality to identify those at risk for inducible myocardial ischemia. Recent data have advanced the understanding of safety and dosing for several anti-inflammatory therapies in KD. New anticoagulation medication, myocardial infarction management, transition of health care for patients with KD, and future directions in research are discussed.

Appropriate Selection of the Initial Diagnostic Catheter for Left Coronary Angiography Using Computed Tomography

PURPOSE

In patients with a dilated ascending aorta, a diagnostic catheter with a larger curve than the Judkins left 4.0 (JL4) is occasionally required to engage the left coronary artery. However, the specific size of the ascending aorta and other parameters have not been sufficiently investigated. We examined the relationship between aortic morphological parameters and the need for a larger catheter size during left coronary angiography (CAG).

METHODS

At our hospital, consecutive patients who underwent both CAG and contrast-enhanced computed tomography (CT) for aorta and coronary imaging were divided into two groups based on the catheter used for left CAG: the JL4 group and the Judkins left 5.0 (JL5) group. Nine selected aortic morphological parameters from the CT images were measured and compared between the two groups.

RESULTS

The JL5 and JL4 groups included 19 and 230 patients, respectively. The JL5 group had higher numbers of coronary diagnostic catheters used, longer procedure times, and greater contrast volumes compared to the JL4 group. Among the nine aortic morphological parameters, significant differences were found in the maximum area and length of the ascending aorta, the total length of the aorta, and the width and depth of the aorta. Multivariate analysis revealed that the maximum area of the ascending aorta was most strongly associated with the need for JL5 in left CAG (odds ratio (95% CI) per 100 mm2, 1.71 (1.33-2.21), p < 0.0001). The cutoff value for the maximum area of the ascending aorta was 1111.2 mm2 (corresponding to an ascending aortic diameter of approximately 38 mm).

CONCLUSION

Selecting a large-curve diagnostic catheter, such as the JL5, as the initial diagnostic catheter for engaging the left coronary artery in patients with an ascending aorta diameter greater than 38 mm on CT may optimize left CAG.

Short-Term Dual Antiplatelet Therapy After Drug-Eluting Stenting in Patients With Acute Coronary Syndromes: A Systematic Review and Network Meta-Analysis

Importance

The optimal duration of dual antiplatelet therapy (DAPT) in patients with acute coronary syndromes (ACS) undergoing percutaneous coronary intervention (PCI) remains under debate.

Objectives

To analyze the efficacy and safety of DAPT strategies in patients with ACS using a bayesian network meta-analysis.

Data Sources

MEDLINE, Embase, Cochrane, and LILACS databases were searched from inception to April 8, 2024.

Study Selection

Randomized clinical trials (RCTs) comparing DAPT duration strategies in patients with ACS undergoing PCI were selected. Short-term strategies (1 month of DAPT followed by P2Y12 inhibitors, 3 months of DAPT followed by P2Y12 inhibitors, 3 months of DAPT followed by aspirin, and 6 months of DAPT followed by aspirin) were compared with conventional 12 months of DAPT.

Data Extraction and Synthesis

This systematic review and network meta-analysis followed the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. The risk ratio (RR) with a 95% credible interval (CrI) was calculated within a bayesian random-effects network meta-analysis. Treatments were ranked using surface under the cumulative ranking (SUCRA).

Main Outcomes and Measures

The primary efficacy end point was major adverse cardiac and cerebrovascular events (MACCE); the primary safety end point was major bleeding.

Results

A total of 15 RCTs randomizing 35 326 patients (mean [SD] age, 63.1 [11.1] years; 26 954 male [76.3%]; 11 339 STEMI [32.1%]) with ACS were included. A total of 24 797 patients (70.2%) received potent P2Y12 inhibitors (ticagrelor or prasugrel). Compared with 12 months of DAPT, 1 month of DAPT followed by P2Y12 inhibitors reduced major bleeding (RR, 0.47; 95% CrI, 0.26-0.74) with no difference in MACCE (RR, 1.00; 95% CrI, 0.70-1.41). No significant differences were observed in MACCE incidence between strategies, although CrIs were wide. SUCRA ranked 1 month of DAPT followed by P2Y12 inhibitors as the best for reducing major bleeding and 3 months of DAPT followed by P2Y12 inhibitors as optimal for reducing MACCE (RR, 0.85; 95% CrI, 0.56-1.21).

Conclusion and Relevance

Results of this systematic review and network meta-analysis reveal that, in patients with ACS undergoing PCI with DES, 1 month of DAPT followed by potent P2Y12 inhibitor monotherapy was associated with a reduction in major bleeding without increasing MACCE when compared with 12 months of DAPT. However, an increased risk of MACCE cannot be excluded, and 3 months of DAPT followed by potent P2Y12 inhibitor monotherapy was ranked as the best option to reduce MACCE. Because most patients receiving P2Y12 inhibitor monotherapy were taking ticagrelor, the safety of stopping aspirin in those taking clopidogrel remains unclear.

Whys and Wherefores of Coronary Arterial Positive Remodeling

Positive remodeling (PR) is an atherosclerotic plaque feature defined as an increase in arterial caliber at the level of an atheroma, in response to increasing plaque burden. The mechanisms that lead to its formation are incompletely understood, but its role in coronary atherosclerosis has major clinical implications. Indeed, plaques with PR have elevated risk of provoking acute cardiac events. Hence, PR figures among the high-risk plaque features that cardiac imaging studies should report. This review aims to provide an overview of the current literature on coronary PR. It outlines the pathophysiology of PR, the different techniques used to assess its presence, and the imaging findings associated to PR, on both noninvasive and invasive studies. This review also summarizes clinical observations, trials, and studies, focused on the impact of PR on clinical outcome.