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

Lower revascularization rates after high-speed rotational atherectomy compared to modified balloons in calcified coronary lesions: 5-year outcomes of the randomized PREPARE-CALC trial

BACKGROUND

In the PREPARE-CALC trial, severely calcified lesion preparation with rotational atherectomy (RA) before biodegradable polymer sirolimus-eluting stent (SES) implantation demonstrated higher procedural success and comparable rates of acute lumen gain and late lumen loss compared to modified balloons (MB) (scoring/cutting). We aimed to analyze the 5-year outcomes of both lesion preparation strategies.

METHODS

PREPARE-CALC randomly assigned 200 patients 1:1 to MB or RA, followed by SES implantation. The principal endpoint of the current analysis was target vessel failure (TVF) at 5 years.

RESULTS

At 5 years, MB had comparable rates of TVF to RA (19% vs. 21%, HR 1.14, 95% CI 0.60-2.16, p = 0.687). Subgroup analysis showed a lesion length treatment interaction, favoring MB for short lesions and RA for long ones (p for interaction = 0.042). Target lesion revascularization (TLR) was significantly less common with RA (12 vs. 3%, HR 0.28, 95% CI 0.08-0.98, p = 0.048). In a multivariate analysis, RA was independently protective against TLR (adj. HR 0.17, 95% CI 0.04-0.78, p = 0.022), while ostial lesions were associated with higher TLR independent of treatment strategy (adj. HR 11.3, 95% CI 2.98-42.6, p < 0.001).

CONCLUSION

In patients with severely calcified coronary lesions, using MB or RA for lesion preparation followed by biodegradable polymer SES implantation was associated with comparable rates of TVF at 5 years. However, a significant reduction of TLR was observed after RA. PREPARE-CALC is the first randomized trial showing potential clinical advantages of RA over MB during long-term follow-up.

CLINICAL TRIAL REGISTRATION

URL: https://www.

CLINICALTRIALS

gov . Unique identifier: NCT02502851.

Duration of Dual Antiplatelet Therapy After Percutaneous Coronary Intervention in Patients With Type 2 Diabetes Mellitus: A Systematic Review and Network Meta-analysis

Background

Patients with type 2 diabetes mellitus (DM) comprise more than a quarter of all patients undergoing percutaneous coronary intervention and are at higher risk of adverse events. We sought to reexamine the optimal duration of dual antiplatelet therapy (DAPT) postpercutaneous coronary intervention in patients with DM.

Methods

We systematically included randomized controlled trials comparing any 2 of 1, 3, 6, and 12 months of DAPT that reported major adverse cardiovascular events (MACE), net adverse clinical events (NACE), bleeding, or stent thrombosis in DM, and performed a frequentist network meta-analysis. We also performed a sensitivity analysis of trials that exclusively enrolled patients with acute coronary syndrome.

Results

In 16 randomized controlled trials comprising 16,376 adults with DM, there was no significant difference in NACE, MACE, stent thrombosis, or major bleeding between pairwise comparisons of 1, 3, 6, and 12 months of DAPT, except for a signal for lower bleeding with 3 months of DAPT compared to 12 (risk ratio, 0.72; 95% CI, 0.51-0.99). Sensitivity analysis of trials that solely included acute coronary syndrome similarly showed no significant difference in MACE between 1, 3, 6, and 12 months of DAPT.

Conclusions

Our study found no meaningful difference in NACE or MACE between pairwise comparisons of 1, 3, 6, and 12 months of DAPT by study-level meta-analysis of patients with DM, with lower bleeding risk observed with 3 months than with 12 months of DAPT. This finding may provide clinicians greater flexibility to personalize patients' DAPT duration based on other non-DM comorbidities that might affect bleeding or thrombosis risk.

Electroacupuncture for slow flow/no-reflow phenomenon in patients with acute myocardial infarction undergoing percutaneous coronary intervention: protocol for a pilot randomized controlled trial

Background

Slow flow/no-reflow (SF-NR) during percutaneous coronary intervention (PCI) is associated with poor prognosis of patients with acute myocardial infarction (AMI). Currently, effective treatment is not available for SF-NR. Electroacupuncture (EA) has shown significant efficacy as an adjuvant therapy for many cardiovascular diseases by improving microcirculation and reducing ischemia-reperfusion injury. However, its effects on SF-NR in the AMI patients during PCI are not clear. This pilot trial aims to determine the efficacy of intraoperative EA in alleviating SF-NR in AMI patients undergoing PCI.

Methods

This prospective, single-center, randomized controlled, pilot trial will recruit 60 AMI patients scheduled for PCI at the Yueyang Hospital of Integrated Traditional Chinese and Western Medicine, China. The patients will be randomized in a 1:1 ratio into the EA or the control groups. Patients in the control group will undergo standard PCI. Patients in the EA group will undergo intraoperative electroacupuncture while undergoing standard PCI. Incidence of SF-NR is the primary outcome for this study. This study will also assess secondary outcomes including cardiac biomarkers, inflammatory biomarkers, pain and anxiety scores, electrocardiography parameters, traditional Chinese medicine (TCM) symptom score, and major adverse cardiovascular and cerebrovascular events (MACCE). All the included patients will undergo laboratory tests including routine blood tests, levels of electrolytes, as well as liver and renal function tests. Patients will be followed up for 1 month after the procedure.

Discussion

This pilot trial will provide evidence for the potential benefits of intraoperative EA in improving microvascular perfusion and preventing or alleviating SF-NR during PCI in patients with AMI. If proven effective, intraoperative EA will provide a new and effective strategy against SF-NR and provide evidence for subsequent multicenter trials.

Clinical Trial Registration

ClinicalTrials.gov, identifier (ChiCTR2300072265). Registered on 8 June 2023.

Acute Coronary Syndrome: Treatment Strategies and Outcomes in Patients Admitted to a Tertiary Care Hospital in Palestine

Background

Acute coronary syndrome (ACS) is the leading cause of death worldwide despite advances in treatment and prevention measures. This study aimed to explore ACS treatment strategies (ischemia-guided vs early invasive) and risk factors among patients diagnosed with ACS in a tertiary care hospital in Palestine and to evaluate related outcomes regarding future events and standard clinical guidelines.

Methods

This retrospective cohort study reviewed patient data from a Palestinian medical hospital. The study included 255 patients ≥ 18 years who were hospitalized between January 2021 and December 2021 and diagnosed with ACS. The data were analyzed using the Statistical Package for Social Science (SPSS).

Results

71% of the participants were males. The mean age was 59.59±11.56 years. Smoking, diabetes, and hypertension were the most common risk factors. Unstable angina (UA) was the most prevalent ACS type, accounting for 43.1% (110) of cases, whereas NSTEMI accounted for 39.2% (100) and STEMI accounted for 17.6% (45) of cases. An ischemic-guided strategy approach was used in 71% (181) of the patients. Upon discharge, the most prescribed medication classes were antiplatelets (97.6%), statins (87.1%), PPIs (72.5%), and antihypertensives (71.8%). Treatment strategies were selected according to the clinical guidelines for most ACS types.

Conclusion

ACS management in Palestine continues to evolve to overcome barriers, decrease patient mortality, and decrease hospital stay. UA and NSTEMI were the most common ACS diagnoses at admission, and the ischemic strategy was the most common modality. The findings of this study call for an increased awareness of CVD risk factors, resource availability, and adherence to clinical guidelines to improve patient outcomes and community health.

Percutaneous Microaxial Ventricular Assist Device Versus Intra-Aortic Balloon Pump for Nonacute Myocardial Infarction Cardiogenic Shock

BACKGROUND

Evidence on the comparative outcomes following percutaneous microaxial ventricular assist devices (pVAD) versus intra-aortic balloon pump for nonacute myocardial infarction cardiogenic shock is limited.

METHODS AND RESULTS

We included 704 and 2140 Medicare fee-for-service beneficiaries aged 65 to 99 years treated with pVAD and intra-aortic balloon pump, respectively, for nonacute myocardial infarction cardiogenic shock from 2016 to 2020. Patients treated using pVAD compared with those treated using intra-aortic balloon pump were more likely to be concurrently treated with mechanical ventilation, renal replacement therapy, and blood transfusions. We computed propensity scores for undergoing pVAD using patient- and hospital-level factors and performed a matching weight analysis. The use of pVAD was associated with higher 30-day mortality (adjusted odds ratio, 1.92 [95% CI, 1.59-2.33]) but not associated with in-hospital bleeding (adjusted odds ratio, 1.00 [95% CI, 0.81-1.24]), stroke (adjusted odds ratio, 0.91 [95% CI, 0.56-1.47]), sepsis (OR, 0.91 [95% CI, 0.64-1.28]), and length of hospital stay (adjusted mean difference, +0.4 days [95% CI, -1.4 to +2.3]). A quasi-experimental instrumental variable analysis using the cross-sectional institutional practice preferences showed similar patterns, though not statistically significant (adjusted odds ratio, 1.38; 95% CI, 0.28-6.89).

CONCLUSIONS

Our investigation using the national sample of Medicare beneficiaries showed that the use of pVAD compared with intra-aortic balloon pump was associated with higher mortality in patients with nonacute myocardial infarction cardiogenic shock. Providers should be cautious about the use of pVAD for nonacute myocardial infarction cardiogenic shock, while adequately powered high-quality randomized controlled trials are warranted to determine the clinical effects of pVAD.

Review of the Ticagrelor Trials Evidence Base

Ticagrelor is a platelet P2Y12 receptor inhibitor approved for use in patients with acute coronary syndromes, coronary artery disease, and low-moderate risk acute ischemic stroke or high-risk transient ischemic attack. Clinical trials have evaluated the efficacy and safety of ticagrelor on ischemic and bleeding outcomes for different indications and with varying treatment approaches. As a result, there is a large body of clinical evidence demonstrating different degrees of net clinical benefit compared with other platelet inhibitor drugs based on indication, patient characteristics, clinical presentation, treatment duration, and other factors. We provide a review of the major trials of ticagrelor in the context of other randomized trials of clopidogrel and prasugrel to organize the volume of available information, elevate corroborating and conflicting data, and identify potential gaps as areas for further exploration of optimal antiplatelet treatment.

Intravascular Imaging and Angiography Guidance in Complex Percutaneous Coronary Intervention Among Patients With Diabetes: A Secondary Analysis of a Randomized Clinical Trial

Importance

Data are limited regarding the effects of intravascular imaging guidance during complex percutaneous coronary intervention (PCI) in patients with diabetes.

Objective

To compare the clinical outcomes of intravascular imaging-guided vs angiography-guided complex PCI in patients with or without diabetes.

Design, Setting, and Participants

This prespecified secondary analysis of a subgroup of patients in RENOVATE-COMPLEX-PCI (Randomized Controlled Trial of Intravascular Imaging Guidance Versus Angiography-Guidance on Clinical Outcomes After Complex Percutaneous Coronary Intervention), an investigator-initiated, open-label multicenter trial, analyzed enrolled patients who underwent complex PCI at 20 sites in Korea from May 2018 through May 2021. Eligible patients were randomly assigned in a 2:1 ratio to undergo either the intravascular imaging-guided PCI or angiography-guided PCI. Data analyses were performed from June 2023 to April 2024.

Interventions

Percutaneous coronary intervention was performed either under the guidance of intravascular imaging or angiography alone.

Main Outcomes and Measures

The primary end point was target vessel failure (TVF), defined as a composite of cardiac death, target vessel-related myocardial infarction, or target vessel revascularization.

Results

Among the 1639 patients included in the analysis (mean [SD] age, 65.6 [10.2] years; 1300 males [79.3%]), 617 (37.6%) had diabetes. The incidence of TVF was significantly higher in patients with diabetes than patients without diabetes (hazard ratio [HR], 1.86; 95% CI, 1.33-2.60; P < .001). Among patients without diabetes, the intravascular imaging-guided PCI group had a significantly lower incidence of TVF compared with the angiography-guided PCI group (4.7% vs 12.2%; HR, 0.41 [95% CI, 0.25-0.67]; P < .001). Conversely, in patients with diabetes, the risk of TVF was not significantly different between the 2 groups (12.9% vs 12.3%; HR, 0.97 [95% CI, 0.60-1.57]; P = .90). There was a significant interaction between the use of intravascular imaging and diabetes for the risk of TVF (P for interaction = .02). Among patients with diabetes, only those with good glycemic control (hemoglobin A1c level ≤7.5%) and who achieved stent optimization by intravascular imaging showed a lower risk of future ischemic events (HR, 0.31; 95% CI, 0.12-0.82; P = .02).

Conclusions and Relevance

In this secondary analysis of a subgroup of patients in the RENOVATE-COMPLEX-PCI trial, intravascular imaging guidance reduced the risk of TVF compared with angiography guidance in patients without diabetes (but not in patients with diabetes) during complex PCI. In patients with diabetes undergoing complex PCI, attention should be paid to stent optimization using intravascular imaging and glycemic control to improve outcomes.

Trial Registration

ClinicalTrials.gov Identifier: NCT03381872.

Routine Functional Testing or Standard Care in High-Risk Patients after Percutaneous Coronary Intervention

PURPOSE OF REVIEW

This review aimed to collate the available evidence on outcomes following routine functional stress testing vs standard of care (i.e. symptom-guided stress testing) in high-risk patients following percutaneous coronary intervention (PCI).

RECENT FINDINGS

The most recent pragmatic POST-PCI trial provided randomized evidence showing that routine functional stress testing post-PCI did not lead to a reduction in 2-year ischemic cardiovascular events or all-cause mortality, as compared to a symptom-guided standard-of-care approach. This was also true for sub-analyses including multivessel or left main disease, diabetics, as well as following imaging or physiology guided PCI. In the absence of a change in their clinical or functional status suggestive of stent failure, post-PCI routine periodic stress testing in stable patients on guideline-directed medical therapy is currently not recommended by American clinical practice guidelines. While evidence on the cost-effectiveness of routine stress testing strategy is scarce, physician, payer, and policy-level interventions to reduce inappropriate use of routine functional testing need to be addressed.

Multi-organ Thromboembolic Crisis: A Case Report of Concomitant Stroke, Myocardial Infarction, and Pulmonary Embolism

Management of acute coronary syndrome (ACS), cerebrovascular accident (CVA), and pulmonary embolism (PE) necessitates prompt intervention, as delayed treatment may lead to severe consequences. Each of these conditions presents significant challenges and carries a high risk of morbidity and mortality. We present the case of an 86-year-old female with a history of stage 4 urothelial carcinoma metastasized to the lungs, who presented to the emergency department (ED) with acute ischemic stroke (AIS), ST-segment elevation myocardial infarction (STEMI), and bilateral PE. We propose the term "multi-organ thromboembolic crisis" (MOTEC) to streamline the communication and management approach for patients experiencing critical thromboembolic events affecting multiple organ systems.

Role of anticoagulation in non-ST-elevation myocardial infarction: a contemporary narrative review

INTRODUCTION

Anticoagulants play a vital role as part of the antithrombotic therapy of myocardial infarction and are complementary to antiplatelet therapies. In the acute setting, the rationale for their use is to antagonize the ongoing clotting cascade including during percutaneous coronary intervention. Anticoagulation may be an important part of the longer-term antithrombotic strategy especially in patients who have other existing indications (e.g. atrial fibrillation) for their use.

AREAS COVERED

In this narrative review, the authors provide a contemporary summary of the anticoagulation strategies of patients presenting with NSTEMI, both in terms of anticoagulation during the acute phase as well as suggested antithrombotic regimens for patients who require long-term anticoagulation for other indications.

EXPERT OPINION

Patients presenting with non-ST-elevation myocardial infarction (NSTEMI) should be initiated on anticoagulation (e.g. heparin/low molecular weight heparin) for the initial hospitalization period for those medically managed or until percutaneous coronary intervention. Longer term management of NSTEMI for patients with an existing indication for long-term anticoagulation should comprise triple antithrombotic therapy of anticoagulant (preferably DOAC) with aspirin and clopidogrel for up to 1 month (typically 1 week or until hospital discharge), followed by DOAC plus clopidogrel for up to 1 year, and then DOAC monotherapy thereafter.

Agreement of Fractional Flow Reserve Estimated by Computed Tomography With Invasively Measured Fractional Flow Reserve: A Systematic Review and Meta-Analysis

BACKGROUND

Fractional flow reserve (FFR) is the ratio of blood pressure measured distal to a stenosis and pressure proximal to a stenosis. FFR can be estimated noninvasively using computed tomography (CT) although the usefulness of this technique remains controversial. This meta-analysis evaluated the agreement of FFR estimated by CT (FFR-CT) with invasively measured FFR. The study also evaluated the diagnostic accuracy of FFR-CT, defined as the ability of FFR-CT to classify lesions as hemodynamically significant (invasive FFR ≤0.8) or insignificant (invasive FFR >0.8).

METHODS AND RESULTS

Forty-three studies reporting on 7291 blood vessels from 5236 patients were included. A moderate positive linear relationship between FFR-CT and invasively measured FFR was observed (Spearman correlation coefficient: 0.67). Agreement between the 2 measures increased as invasively measured FFR values approached 1. The overall diagnostic accuracy, sensitivity and specificity of FFR-CT were 82.2%, 80.9%, and 83.1%, respectively. Diagnostic accuracy of 90% could be demonstrated for FFR-CT values >0.90 and <0.49. The diagnostic accuracy of off-site tools was 79.4% and the diagnostic accuracy of on-site tools was 84.1%.

CONCLUSIONS

The agreement between FFR-CT and invasive FFR is moderate although agreement is highest in vessels with FFR-CT >0.9. Diagnostic accuracy varies widely with FFR-CT value but is above 90% for FFR-CT values >0.90 and <0.49. Furthermore, on-site and off-site tools have similar performance. Ultimately, FFR-CT may be a useful adjunct to CT coronary angiography as a gatekeeper for invasive coronary angiogram.

Prognostic value of elevated lipoprotein (a) in patients with acute coronary syndromes: a systematic review and meta-analysis

Background

Elevated lipoprotein (a) level was recognized as an independent risk factor for significant adverse cardiovascular events in acute coronary syndrome (ACS) patients. Despite this recognition, the consensus in the literature regarding the prognostic significance of elevated lipoprotein (a) in ACS was also limited. Consequently, we conducted a thorough systematic review and meta-analysis to evaluate the prognostic relevance of elevated lipoprotein (a) level in individuals diagnosed with ACS.

Methods and results

A thorough literature review was conducted by systematically searching PubMed, Embase, and Cochrane databases until September 2023. This review specifically examined cohort studies exploring the prognostic implications of elevated lipoprotein (a) level in relation to major adverse cardiovascular events (MACE), including death, stroke, non-fatal myocardial infarction (MI), and coronary revascularization, in patients with ACS. The meta-analysis utilized aggregated multivariable hazard ratios (HR) and their respective 95% confidence intervals (CI) to evaluate prognostic implications between high and low lipoprotein (a) levels [the cut-off of high lipoprotein (a) level varies from 12.5 to 60 mg/dl]. Among 18,168 patients in the identified studies, elevated lipoprotein (a) was independently associated with increased MACE risk (HR 1.26; 95% CI: 1.17-1.35, P < 0.00001) and all-cause mortality (HR 1.36; 95% CI: 1.05-1.76, P = 0.02) in ACS patients. In summary, elevated lipoprotein (a) levels independently forecast MACE and all-cause mortality in ACS patients. Assessing lipoprotein (a) levels appears promising for risk stratification in ACS, offering valuable insights for tailoring secondary prevention strategies.

Systematic Review Registration

PROSPERO (CRD42023476543).

Clinical Value of Single-Projection Angiography-Derived FFR in Noninfarct-Related Artery

BACKGROUND

The Murray law-based quantitative flow ratio (μFR) is an emerging technique that requires only 1 projection of coronary angiography with similar accuracy to quantitative flow ratio (QFR). However, it has not been validated for the evaluation of noninfarct-related artery (non-IRA) in acute myocardial infarction (AMI) settings. Therefore, our study aimed to evaluate the diagnostic accuracy of μFR and the safety of deferring non-IRA lesions with μFR >0.80 in the setting of AMI.

METHODS

μFR and QFR were analyzed for non-IRA lesions of patients with AMI enrolled in the FRAME-AMI trial (Fractional Flow Reserve Versus Angiography-Guided Strategy for Management of Non-Infarction Related Artery Stenosis in Patients With Acute Myocardial Infarction), consisting of fractional flow reserve (FFR)-guided percutaneous coronary intervention and angiography-guided percutaneous coronary intervention groups. The diagnostic accuracy of μFR was compared with QFR and FFR. Patients were classified by the non-IRA μFR value of 0.80 as a cutoff value. The primary outcome was a vessel-oriented composite outcome, a composite of cardiac death, non-IRA-related myocardial infarction, and non-IRA-related repeat revascularization.

RESULTS

μFR and QFR analyses were feasible in 443 patients (552 lesions). μFR showed acceptable correlation with FFR (R=0.777; P<0.001), comparable C-index with QFR to predict FFR ≤0.80 (μFR versus QFR: 0.926 versus 0.961, P=0.070), and shorter total analysis time (mean, 32.7 versus 186.9 s; P<0.001). Non-IRA with μFR >0.80 and deferred percutaneous coronary intervention had a significantly lower risk of vessel-oriented composite outcome than non-IRA with performed percutaneous coronary intervention (3.4% versus 10.5%; hazard ratio, 0.37 [95% CI, 0.14-0.99]; P=0.048).

CONCLUSIONS

In patients with multivessel AMI, μFR of non-IRA showed acceptable diagnostic accuracy comparable to that of QFR to predict FFR ≤0.80. Deferred non-IRA with μFR >0.80 showed a lower risk of vessel-oriented composite outcome than revascularized non-IRA.

REGISTRATION

URL: https://www.clinicaltrials.gov; Unique identifier: NCT02715518.

Role of Brain-Derived Neurotrophic Factor in Anxiety or Depression After Percutaneous Coronary Intervention

Anxiety or depression after percutaneous coronary intervention (PCI) is one of the key clinical problems in cardiology that need to be solved urgently. Brain-derived neurotrophic factor (BDNF) may be a potential biomarker for the pathogenesis and treatment of anxiety or depression after PCI. This article reviews the correlation between BDNF and cardiovascular system and nervous system from the aspects of synthesis, release and action site of BDNF, and focuses on the latest research progress of the mechanism of BDNF in anxiety or depression after PCI. It includes the specific mechanisms by which BDNF regulates the levels of inflammatory factors, reduces oxidative stress damage, and mediates multiple signaling pathways. In addition, this review summarizes the therapeutic potential of BDNF as a potential biomarker for anxiety or depression after PCI.

Clinical significance of R-wave amplitude in lead V1 and inferobasal myocardial infarction in patients with inferior wall myocardial infarction

OBJECTIVE

To assess electrocardiogram (ECG) for risk stratification in inferior ST-elevation myocardial infarction (STEMI) patients within 24 h.

METHODS

Three hundred thirty-four patients were divided into four ECG-based groups: Group A: R V1 <0.3 mV with ST-segment elevation (ST↑) V7-V9, Group B: R V1 <0.3 mV without ST↑ V7-V9, Group C: R V1 ≥0.3 mV with ST↑ V7-V9, and Group D: R V1 ≥0.3 mV without ST↑ V7-V9.

RESULTS

Group A demonstrated the longest QRS duration, followed by Groups B, C, and D. ECG signs for right ventricle (RV) infarction were more common in Groups A and B (p < .01). ST elevation in V6, indicative of left ventricle (LV) lateral injury, was more higher in Group C than in Group A, while the ∑ST↑ V3R + V4R + V5R, representing RV infarction, showed the opposite trend (p < .05). The estimated LV infarct size from ECG was similar between Groups A and C, yet Group A had higher creatine kinase MB isoform (CK-MB; p < .05). Cardiac troponin I (cTNI) was higher in Groups A and C than in B and D (p < .05 and p = .16, respectively). NT-proBNP decreased across groups (p = .20), with the highest left ventricular ejection fraction (LVEF) observed in Group D (p < .05). Group A notably demonstrated more cardiac dysfunction within 4 h post-onset.

CONCLUSIONS

For inferior STEMI patients, concurrent R V1 <0.3 mV with ST↑ V7-V9 suggests prolonged ventricular activation and notable myocardial damage. RV infarction's dominance over LV lateral injury might explain these observations.

A Comparison of 2 Paclitaxel-Coated Balloon Systems in Treatment of De Novo Coronary Artery Lesions

Background

In percutaneous coronary intervention (PCI) of de novo lesions, drug-coated balloons (DCB) have been shown to be a promising strategy to improve clinical outcomes of patients with small vessel disease. Evidence of this strategy in PCI of de novo coronary lesions in a real-world setting is limited. The objective of this study was to compare the 12-month outcomes of 2 paclitaxel-coated balloon systems for the treatment of all de novo coronary artery lesions.

Methods

All patients who were treated for de novo coronary artery stenosis with either SeQuent Please or In.Pact Falcon DCB at a single center from January 2014 to December 2018 were included. The primary end point was the composite of cardiac death, nonfatal myocardial infarction, and target vessel revascularization (3-point major adverse cardiovascular events) at 12 months.

Results

A total of 496 patients with 623 lesions, of which 144 were treated with SeQuent Please and 352 were treated with In.Pact Falcon were included in the study. Baseline patient, lesion and procedural characteristics at baseline were similar between groups. At 12-month follow-up, 3-point major adverse cardiovascular event outcomes were similar (4.2% vs 2.3% respectively; P = .272). Deaths due to cardiovascular events were few and similar between groups (2.7% vs 1.1% respectively; P = .20).

Conclusions

Both paclitaxel DCB systems have similar efficacy and safety outcomes, suggesting that both may be an appropriate treatment choice for patients with de novo lesions. However, a larger randomized controlled study is needed to confirm these findings.

When to Consider Coronary Revascularization for Stable Coronary Artery Disease

Revascularization is an effective adjunct to medical therapy for some patients with chronic coronary disease. Despite numerous randomized trials, there remains significant uncertainty regarding if and how to revascularize many patients. Coronary artery bypass grafting is a class I indication for patients with significant left main stenosis or multivessel disease with ejection fraction ≤ 35%. For other patients, clinicians must carefully consider the potential benefits of symptom improvement and reduction of future myocardial infarction or CV death against the risk and cost of revascularization. Although guidelines provide a framework for these decisions, each individual patient will have distinct coronary anatomy, clinical factors, and preferences.

Correlations Between Acute Coronary Syndrome and Novel Inflammatory Markers (Systemic Immune-Inflammation Index, Systemic Inflammation Response Index, and Aggregate Index of Systemic Inflammation) in Patients with and without Diabetes or Prediabetes

Purpose

Type 2 diabetes mellitus (DM) is a recognized independent risk factor for both chronic coronary syndrome (CCS) and its complication, acute coronary syndrome (ACS). Patients with DM and prediabetes (preDM) face an increased ACS risk. Inflammation plays a significant role in the pathogenesis of both CCS and ACS. This study delves into novel inflammatory markers, such as the systemic immune-inflammation index (SII), systemic inflammation response index (SIRI), and aggregate index of systemic inflammation (AISI, also known as SIIRI or PIV), to explore their relationship with ACS and CCS in patients that have been or have not been diagnosed with DM or preDM.

Patients and Methods

This study included data of 493 patients with chest pain undergoing coronary angiography. They were categorized into four groups: 1) without DM/preDM and with CCS; 2) with both DM/preDM and CCS; 3) without DM/preDM and with ACS, 4) with both DM/preDM and ACS. Standard methods of statistical analysis were used to reveal possible differences between groups and to find the most influential ACS risk factors in groups with DM/preDM and without DM/preDM.

Results

The analysis showed no significant differences in SII, SIRI, or AISI between the respective patient groups. A logistic regression analysis generated a model incorporating SII, high-density lipoprotein, and low-density lipoprotein levels as the influential ACS risk factors for patients with DM/preDM. The model demonstrated 71.0% accuracy, 37.0% sensitivity, and 89.4% specificity.

Conclusion

The findings suggest that the aforementioned inflammatory markers may have potential for distinguishing DM/preDM patients at higher risk of ACS at a low financial cost. However, further comprehensive and well-designed research is required to validate their clinical utility.

Cardiogenic Shock in Older Adults: A Focus on Age-Associated Risks and Approach to Management: A Scientific Statement From the American Heart Association

Cardiogenic shock continues to portend poor outcomes, conferring short-term mortality rates of 30% to 50% despite recent scientific advances. Age is a nonmodifiable risk factor for mortality in patients with cardiogenic shock and is often considered in the decision-making process for eligibility for various therapies. Older adults have been largely excluded from analyses of therapeutic options in patients with cardiogenic shock. As a result, despite the association of advanced age with worse outcomes, focused strategies in the assessment and management of cardiogenic shock in this high-risk and growing population are lacking. Individual programs oftentimes develop upper age limits for various interventional strategies for their patients, including heart transplantation and durable left ventricular assist devices. However, age as a lone parameter should not be used to guide individual patient management decisions in cardiogenic shock. In the assessment of risk in older adults with cardiogenic shock, a comprehensive, interdisciplinary approach is central to developing best practices. In this American Heart Association scientific statement, we aim to summarize our contemporary understanding of the epidemiology, risk assessment, and in-hospital approach to management of cardiogenic shock, with a unique focus on older adults.

Feasibility and Diagnostic Performance of Functional SYNTAX Score Derived From Dynamic CT Myocardial Perfusion Imaging

BACKGROUND

Computed tomography (CT) fractional flow reserve (FFR)-derived functional SYNTAX score (FSSCT-FFR) is a valuable method for guiding treatment strategy in patients with multivessel coronary artery disease. Dynamic CT myocardial perfusion imaging (CT-MPI) demonstrates higher diagnostic accuracy than CT-FFR in identifying hemodynamically significant coronary artery disease. We aimed to evaluate the feasibility of CT-MPI-derived FSS (FSSCT-MPI) with reference to invasive FSS.

METHODS

In this retrospective study, patients with multivessel coronary artery disease who underwent dynamic CT-MPI+ coronary CT angiography and invasive coronary angiography or FFR within 4 weeks were consecutively included. Invasive (FSSinvasive) and noninvasive FSS (FSSCT-MPI and FSSCT-FFR) were calculated by an online calculator, which assigned points to lesions with hemodynamic significance (defined as FFRinvasive ≤0.80, invasive coronary angiography diameter stenosis ≥90%, CT-FFR ≤0.80, and myocardial ischemia on CT-MPI). Weighted κ value and net reclassification index were calculated to determine the consistency and incremental discriminatory power of FSSCT-MPI. Receiver operating characteristic curve analysis was used for the comparison of FSSCT-MPI and FSSCT-FFR in detecting intermediate- to high-risk patients.

RESULTS

A total of 119 patients (96 men; 64.6±10.6 years) with 305 obstructive lesions were included. The average FSSCT-MPI, FSSCT-FFR, and FSSinvasive were 15.58±13.03, 16.18±13.30, and 13.11±12.22, respectively. The agreement on risk classification based on the FSSCT-MPI tertiles was good (weighted κ, 0.808). With reference to FSSinvasive, FSSCT-MPI correctly reclassified 27 (22.7%) patients from the intermediate- to high SYNTAX score group to the low-score group (net reclassification index, 0.30; P<0.001). In patients with severe calcification, FSSCT-MPI had better diagnostic value than FSSCT-FFR in detecting intermediate- to high-risk patients when compared with FSSinvasive (area under the curve, 0.976 versus 0.884; P<0.001).

CONCLUSIONS

Noninvasive FSS derived from CT-MPI is feasible and has strong concordance with FSSinvasive. It allows accurate categorization of FSS in patients with multivessel coronary artery disease, in particular with severe calcification.

Managing STEMIs without a Catheterization Lab: A Simulated Scenario to Improve Emergency Clinician Recognition and Execution of Thrombolysis in the Setting of Rural STEMI Management

Audience

The targeted audience for this simulation is Emergency Medicine (EM) residents. Medical students, advanced practice providers, and staff physicians could all also find educational merit in this scenario.

Background

Cardiovascular disease is the leading cause of death in the United States according to the CDC.1 Coronary artery disease caused 375,000 deaths 2021 alone, and about 5% of all adult patients have a prior history of coronary artery disease.2 Furthermore, chest pain itself is a common chief complaint encountered in the ED, with nearly 8 million visits annually occurring throughout the United States, with 10-20% of those patients ultimately being diagnosed with an acute coronary syndrome3, including ST-elevation myocardial infarction (STEMI). Given this, it is essential that EM residents are well prepared to care for all patients presenting with chest pain, regardless of the acute care or emergency setting.Throughout their training, most EM residents typically learn and evaluate patients at a large tertiary or quaternary medical center with 24-hour catheterization laboratory availability. For patients presenting with electrocardiogram (EKG) findings consistent with STEMI, the standard of care is for the patient to undergo cardiac catheterization and stent placement within 90 minutes of arrival. Unfortunately, only half of patients living in rural areas have a cardiac catheterization-capable facility available to them within a 60-minute driving radius, making it difficult for those patients to undergo cardiac catheterization within the desired time frame.4 These patients remain candidates for thrombolytic therapy, but given infrequent opportunities to learn about and deploy thrombolytic agents during residency training, graduating EM residents may be unfamiliar with indications, dosing, and contraindications before they begin practice. Furthermore, the recent EM workforce data suggests that although there may be an oversupply of 8,000 emergency physicians by 2030, robust practice opportunities for emergency physicians remain in rural settings.5 Although historically EM graduates have not selected rural areas for practice, with only approximately 8% of emergency physicians practicing in rural areas,6 it is likely that given the opportunities present and perceived saturation in many non-rural settings, more EM graduates will pursue practice in a rural setting. With these changing practice dynamics in mind, this simulation provides the opportunity for residents and medical students to experience the management of a STEMI in the rural setting, with a focus upon the indications, contraindications, dosing, and disposition of a patient receiving thrombolytics.

Educational Objectives

By the end of this simulation, learners will be able to:Diagnose ST elevation myocardial infarction accurately and initiate thrombolysis in the rural setting without timely access to cardiac catheterization.Engage the simulated patient in a shared decision-making conversation, clearly outlying the benefits and risks of thrombolysis.Identify the indications and contraindications for thrombolysis in ST elevation myocardial infarction.Arrange for transfer to a tertiary care center following completion of thrombolysis.

Educational Methods

This scenario is a simulated encounter in a rural emergency department setting requiring the diagnosis of a STEMI, a discussion with the patient regarding the risks and benefits of thrombolysis prior to administration, administration of thrombolysis, and transfer of patient to a higher level of care.

Research Methods

The educational content of this simulation as a teaching instrument was evaluated by the learner utilizing an internally developed survey after case completion. This survey was reviewed for precision of language and assessment of learning objectives by our simulation faculty and other members of our West Virginia University Emergency Medicine Department of Medical Education. The learner was asked to specify any prior experience with rural STEMI management as well as quantify via a five-point Likert Scale, where 1 = very uncomfortable and 5 = very comfortable, their level of comfort with thrombolysis before and after the scenario as well as their comfort with having a shared decision-making conversation with patients with regards to thrombolysis. Learners were also asked to rank the helpfulness of this simulation in preparing them for administering thrombolytics for STEMI in a rural setting on a five-point Likert scale, where 1 = not helpful and 5 =very helpful. An open response section was also provided to allow learners the opportunity to comment directly on any aspect of the simulation.

Results

Data was collected anonymously from 16 PGY1-3 resident learners via surveys with a 100% response rate. Overall, the feedback received regarding the simulation was positive. There was a low average comfort level with administering thrombolytics and having a shared decision-making conversation regarding administering thrombolytics. There was a high average rating of the helpfulness of this simulation in preparing residents for this conversation as well as managing STEMIs in a rural setting. Subjective comments regarding the simulation were universally positive.

Discussion

The management of STEMI in the rural emergency department differs significantly from the environment in which many EM residents train. As a leading cause of death in the United States, STEMI management is a vital component of EM resident education. Although the concept of thrombolysis in the rural setting is discussed, the opportunity for real-world experience in its execution is often limited despite many graduates ultimately working in rural emergency departments. This simulation sought to provide a realistic patient encounter to promote familiarity and comfort in the identification, patient discussion and execution of thrombolysis in the treatment of a STEMI. The educational content was shown to be effective via learner survey completion.

Fried Frailty Phenotype in Elderly Patients with Chronic Coronary Syndrome: Prevalence, Associated Factors, and Impact on Hospitalization

Purpose

To investigate the prevalence and factors associated with frailty and impact of frailty on hospitalization due to any cause in elderly patients with chronic coronary syndrome (CCS).

Patients and Methods

We conducted a study wherein we assessed frailty using Fried frailty phenotype for outpatients aged ≥60 years with CCS. Logistic regression analysis was performed to assess the factors associated with frailty. Frailty was adjusted for demographic and geriatric variables and comorbidities to assess its impact on hospitalization.

Results

Overall, 420 patients (median age 70 years [interquartile range, 65-77]; men, 74.5%) who completed the 3-month follow-up period were analyzed. Coronary revascularization for > 1 year was the most common clinical scenario for CCS (59.8%; n = 251). The prevalence of non-frail, pre-frail, and frail patients were 22.4% (n = 94), 49.7% (n = 209), and 27.9% (n = 117), respectively. In the adjusted model, three factors associated with frailty were age ≥ 75 years (odds ratio [OR] 2.29, 95% confidence interval [CI] 1.39-3.75, P = 0.001), limitations in instrumental activity of daily living (OR 3.89, 95% CI 2.33-6.48, P < 0.001), and heart failure (OR 2.30, 95% CI 1.32-4.02, P = 0.003). The overall 3-month hospitalization rate was higher in frail patients than in non-frail patients (23.9% vs 13.5%, P = 0.012). Frailty was associated with hospitalization (OR 1.85, 95% CI 1.04-3.30, P = 0.037) but in a weak strength of association (r = 0.126).

Conclusion

The prevalence of frailty was 27.9% in the elderly patients with CCS. Age ≥ 75 years, limitations in functional status, and heart failure were associated with increased odds of frailty. Frailty was a predictor of 3-month all-cause hospitalization in these patients.

Association of HbA1c and utilization of internal mammary arteries with wound infections in CABG

Background

Deep sternal wound infection (DSWI) remains a serious complication after coronary artery bypass grafting (CABG). We herein aimed to stratify diabetic patients who underwent CABG using bilateral internal mammary artery (BIMA) for levels of glycated hemoglobin A1C (HbA1c) and compare postoperative outcomes.

Methods

Between January 2010 and August 2020, 4,186 consecutive patients underwent isolated CABG at our center. In 3,229 patients, preoperative HbA1c levels were available. Primary endpoints were wound healing disorder (WHD), DSWI, and 30-day mortality. Patients were stratified according to preoperative HbA1c levels. Patients were further divided into subgroups according to utilization of BIMA.

Results

After adjustment, no differences in mortality and stroke rates were seen between group 1 (HbA1c < 6.5%) vs. group 2 (HbA1c ≥ 6.5%). WHD was more frequent in group 2 [2.8 vs. 5.6%; adjusted p = 0.002; adjusted odds ratio (OR), 1.853 (1.243-2.711)] but not DSWI [1.0 vs. 1.5%; adjusted p = 0.543; adjusted OR, 1.247 (0.612-2.5409)]. BIMA use showed a higher rate of WHD [no BIMA: 3.0%; BIMA: 7.7%; adjusted p = 0.002; adjusted OR, 4.766 (1.747-13.002)] but not DSWI [no BIMA: 1.1%; BIMA: 1.8%; adjusted p = 0.615; adjusted OR, 1.591 (0.260-9.749)] in patients with HbA1c ≥ 6.5%.

Conclusions

Intraoperative utilization of BIMA is not connected with an increase of DSWI but higher rates of WHD in patients with poor diabetic status and HbA1c ≥ 6.5%. Therefore, application of BIMA should be taken into consideration even in patients with poor diabetic status, while identification of special subsets of patients who are at particular high risk for DSWI is of paramount importance to prevent this serious complication.

Genetic-Guided Pharmacotherapy for Coronary Artery Disease: A Systematic and Critical Review of Economic Evaluations

BACKGROUND

Genetic-guided pharmacotherapy (PGx) is not recommended in clinical guidelines for coronary artery disease (CAD). We aimed to examine the extent and quality of evidence from economic evaluations of PGx in CAD and to identify variables influential in changing conclusions on cost-effectiveness.

METHODS AND RESULTS

From systematic searches across 6 databases, 2 independent reviewers screened, included, and rated the methodological quality of economic evaluations of PGx testing to guide pharmacotherapy for patients with CAD. Of 35 economic evaluations included, most were model-based cost-utility analyses alone, or alongside cost-effectiveness analyses of PGx testing to stratify patients into antiplatelets (25/35), statins (2/35), pain killers (1/35), or angiotensin-converting enzyme inhibitors (1/35) to predict CAD risk (8/35) or to determine the coumadin doses (1/35). To stratify patients into antiplatelets (96/151 comparisons with complete findings of PGx versus non-PGx), PGx was more effective and more costly than non-PGx clopidogrel (28/43) but less costly than non-PGx prasugrel (10/15) and less costly and less effective than non-PGx ticagrelor (22/25). To predict CAD risk (51/151 comparisons), PGx using genetic risk scores was more effective and less costly than clinical risk score (13/17) but more costly than no risk score (16/19) or no treatment (9/9). The remaining comparisons were too few to observe any trend. Mortality risk was the most common variable (47/294) changing conclusions.

CONCLUSIONS

Economic evaluations to date found PGx to stratify patients with CAD into antiplatelets or to predict CAD risk to be cost-effective, but findings varied based on the non-PGx comparators, underscoring the importance of considering local practice in deciding whether to adopt PGx.

Cost-Effectiveness of Intravascular Imaging-Guided Complex PCI: Prespecified Analysis of RENOVATE-COMPLEX-PCI Trial

BACKGROUND

Although clinical benefits of intravascular imaging-guided percutaneous coronary intervention (PCI) in patients with complex coronary artery lesions have been observed in previous trials, the cost-effectiveness of this strategy is uncertain.

METHODS

RENOVATE-COMPLEX-PCI (Randomized Controlled Trial of Intravascular Imaging Guidance vs Angiography-Guidance on Clinical Outcomes After Complex Percutaneous Coronary Intervention) was conducted in Korea between May 2018 and May 2021. This prespecified cost-effectiveness substudy was conducted using Markov model that simulated 3 states: (1) post-PCI, (2) spontaneous myocardial infarction, and (3) death. A simulated cohort was derived from the intention-to-treat population, and input parameters were extracted from either the trial data or previous publications. Cost-effectiveness was evaluated using time horizon of 3 years (within trial) and lifetime. The primary outcome was incremental cost-effectiveness ratio (ICER), an indicator of incremental cost on additional quality-adjusted life years (QALYs) gained, in intravascular imaging-guided PCI compared with angiography-guided PCI. The current analysis was performed using the Korean health care sector perspective with reporting the results in US dollar (1200 Korean Won, ₩=1 dollar, $). Willingness to pay threshold was $35 000 per QALY gained.

RESULTS

A total of 1639 patients were included in the trial. During 3-year follow-up, medical costs ($8661 versus $7236; incremental cost, $1426) and QALY (2.34 versus 2.31; incremental QALY, 0.025) were both higher in intravascular imaging-guided PCI than angiography-guided PCI, resulting incremental cost-effectiveness ratio of $57 040 per QALY gained within trial data. Conversely, lifetime simulation showed total cumulative medical cost was reversed between the 2 groups ($40 455 versus $49 519; incremental cost, -$9063) with consistently higher QALY (8.24 versus 7.89; incremental QALY, 0.910) in intravascular imaging-guided PCI than angiography-guided PCI, resulting in a dominant incremental cost-effectiveness ratio. Consistently, 70% of probabilistic iterations showed cost-effectiveness of intravascular imaging-guided PCI in probabilistic sensitivity analysis.

CONCLUSIONS

The current cost-effectiveness analysis suggests that imaging-guided PCI is more cost-effective than angiography-guided PCI by reducing medical cost and increasing quality-of-life in complex coronary artery lesions in long-term follow-up.

REGISTRATION

URL: https://www.clinicaltrials.gov; Unique identifier: NCT03381872.

Diagnostic Performance of Angiography-Derived Quantitative Flow Ratio in Complex Coronary Lesions

BACKGROUND

Quantitative flow ratio derived from computed tomography angiography (CT-QFR) and invasive coronary angiography (Murray law-based quantitative flow ratio [μQFR]) are novel approaches enabling rapid computation of fractional flow reserve without the use of pressure guidewires and vasodilators. However, the feasibility and diagnostic performance of both CT-QFR and μQFR in evaluating complex coronary lesions remain unclear.

METHODS

Between September 2014 and September 2021, 240 patients with 30% to 90% coronary diameter stenosis who underwent both coronary computed tomography angiography and invasive coronary angiography with fractional flow reserve within 60 days were retrospectively enrolled. The diagnostic performance of CT-QFR and μQFR in detecting functional ischemia among all lesions, especially complex coronary lesions, was analyzed using fractional flow reserve as the reference standard.

RESULTS

CT-QFR and μQFR analyses were performed on 309 and 289 vessels, respectively. The diagnostic sensitivity, specificity, positive predictive value, negative predictive value, and accuracy for CT-QFR in all lesions at the per-vessel level were 91% (with a 95% CI of 84%-96%), 92% (95% CI, 88%-95%), 83% (95% CI, 75%-90%), 96% (95% CI, 93%-98%), and 92% (95% CI, 88%-95%), with values for μQFR of 90% (95% CI, 81%-95%), 97% (95% CI, 93%-99%), 92% (95% CI, 84%-97%), 96% (95% CI, 92%-98%), and 94% (95% CI, 91%-97%), respectively. Among bifurcation, tandem, and moderate-to-severe calcified lesions, the diagnostic values of CT-QFR and μQFR showed great correlation and agreement with those of invasive fractional flow reserve, achieving an area under the receiver operating characteristic curve exceeding 0.9 for each complex lesion at the vessel level. Furthermore, the accuracies of CT-QFR and μQFR in the gray zone were 85% and 84%, respectively.

CONCLUSIONS

Angiography-derived quantitative flow ratio (CT-QFR and μQFR) demonstrated remarkable diagnostic performance in complex coronary lesions, indicating its pivotal role in the management of patients with coronary artery disease.

Stopping Aspirin Within 1 Month After Stenting for Ticagrelor Monotherapy in Acute Coronary Syndrome: The T-PASS Randomized Noninferiority Trial

BACKGROUND

Stopping aspirin within 1 month after implantation of a drug-eluting stent for ticagrelor monotherapy has not been exclusively evaluated for patients with acute coronary syndrome. The aim of this study was to investigate whether ticagrelor monotherapy after <1 month of dual antiplatelet therapy (DAPT) is noninferior to 12 months of ticagrelor-based DAPT for adverse cardiovascular and bleeding events in patients with acute coronary syndrome.

METHODS

In this randomized, open-label, noninferiority trial, 2850 patients with acute coronary syndrome who underwent drug-eluting stent implantation at 24 centers in South Korea were randomly assigned (1:1) to receive either ticagrelor monotherapy (90 mg twice daily) after <1 month of DAPT (n=1426) or 12 months of ticagrelor-based DAPT (n=1424) between April 24, 2019, and May 31, 2022. The primary end point was the net clinical benefit as a composite of all-cause death, myocardial infarction, definite or probable stent thrombosis, stroke, and major bleeding at 1 year after the index procedure in the intention-to-treat population. Key secondary end points were the individual components of the primary end point.

RESULTS

Among 2850 patients who were randomized (mean age, 61 years; 40% ST-segment-elevation myocardial infarction), 2823 (99.0%) completed the trial. Aspirin was discontinued at a median of 16 days (interquartile range, 12-25 days) in the group receiving ticagrelor monotherapy after <1 month of DAPT. The primary end point occurred in 40 patients (2.8%) in the group receiving ticagrelor monotherapy after <1-month DAPT, and in 73 patients (5.2%) in the ticagrelor-based 12-month DAPT group (hazard ratio, 0.54 [95% CI, 0.37-0.80]; P<0.001 for noninferiority; P=0.002 for superiority). This finding was consistent in the per-protocol population as a sensitivity analysis. The occurrence of major bleeding was significantly lower in the ticagrelor monotherapy after <1-month DAPT group compared with the 12-month DAPT group (1.2% versus 3.4%; hazard ratio, 0.35 [95% CI, 0.20-0.61]; P<0.001).

CONCLUSIONS

This study provides evidence that stopping aspirin within 1 month for ticagrelor monotherapy is both noninferior and superior to 12-month DAPT for the 1-year composite outcome of death, myocardial infarction, stent thrombosis, stroke, and major bleeding, primarily because of a significant reduction in major bleeding, among patients with acute coronary syndrome receiving drug-eluting stent implantation. Low event rates, which may suggest enrollment of relatively non-high-risk patients, should be considered in interpreting the trial.

REGISTRATION

URL: https://www.clinicaltrials.gov; Unique identifier: NCT03797651.

Intravascular Ultrasound-Guided versus Angiography-Guided Percutaneous Coronary Intervention for Stent Thrombosis Elevation Myocardial Infarction: An Updated Systematic Review and Meta-Analysis

INTRODUCTION

Intravascular ultrasound (IVUS) provides intra-procedural guidance in optimizing percutaneous coronary interventions (PCI) and has been shown to improve clinical outcomes in stent implantation. However, current data on the benefit of IVUS during PCI in ST-elevation myocardial infarction (STEMI) patients is mixed. We performed meta-analysis pooling available data assessing IVUS-guided versus angiography-guided PCI in STEMI patients.

METHODS

We conducted a systematic search on PubMed and Embase for studies comparing IVUS versus angiography-guided PCI in STEMI. Mantel-Haenszel random effects model was used to calculate risk ratios (RRs) with 95% confidence intervals (CIs) for outcomes of major adverse cardiovascular events (MACEs), death, myocardial infarction (MI), target vessel revascularization (TVR), stent thrombosis (ST) and in-hospital mortality.

RESULTS

A total of 8 studies including 336,649 individuals presenting with STEMI were included for the meta-analysis. Follow-up ranged from 11 to 60 months. We found significant association between IVUS-guided PCI with lower risk for MACE (RR 0.82, 95% CI 0.76-0.90) compared with angiography-guided PCI. We also found significant association between IVUS-guided PCI with lower risk for death, MI, TVR, and in-hospital mortality but not ST.

CONCLUSION

In our meta-analysis, IVUS-guided compared with angiography-guided PCI was associated with improved long-term and short-term clinical outcomes in STEMI patients.

Dynamic Prognosis Prediction for Patients on DAPT After Drug-Eluting Stent Implantation: Model Development and Validation

BACKGROUND

The rapid evolution of artificial intelligence (AI) in conjunction with recent updates in dual antiplatelet therapy (DAPT) management guidelines emphasizes the necessity for innovative models to predict ischemic or bleeding events after drug-eluting stent implantation. Leveraging AI for dynamic prediction has the potential to revolutionize risk stratification and provide personalized decision support for DAPT management.

METHODS AND RESULTS

We developed and validated a new AI-based pipeline using retrospective data of drug-eluting stent-treated patients, sourced from the Cerner Health Facts data set (n=98 236) and Optum's de-identified Clinformatics Data Mart Database (n=9978). The 36 months following drug-eluting stent implantation were designated as our primary forecasting interval, further segmented into 6 sequential prediction windows. We evaluated 5 distinct AI algorithms for their precision in predicting ischemic and bleeding risks. Model discriminative accuracy was assessed using the area under the receiver operating characteristic curve, among other metrics. The weighted light gradient boosting machine stood out as the preeminent model, thus earning its place as our AI-DAPT model. The AI-DAPT demonstrated peak accuracy in the 30 to 36 months window, charting an area under the receiver operating characteristic curve of 90% [95% CI, 88%-92%] for ischemia and 84% [95% CI, 82%-87%] for bleeding predictions.

CONCLUSIONS

Our AI-DAPT excels in formulating iterative, refined dynamic predictions by assimilating ongoing updates from patients' clinical profiles, holding value as a novel smart clinical tool to facilitate optimal DAPT duration management with high accuracy and adaptability.

First In-Vivo demonstration of 1000fps High Speed Coronary Angiography (HSCA) in a swine animal model

High-speed-angiography (HSA) 1000 fps imaging was successfully used previously to visualize contrast media/blood flow in neurovascular anatomies. In this work we explore its usage in cardiovascular anatomies in a swine animal model. A 5 French catheter was guided into the right coronary artery of a swine, followed by the injection of iodine contrast through a computer-controlled injector at a controlled rate of 40 (ml/min). The injection process was captured using high-speed angiography at a rate of 1000 fps. The noise in the images was reduced using a custom built machine-learning model consisting of Long Short-term memory networks. From the noise reduced images, velocity profiles of contrast/blood flow through the artery was calculated using Horn-Schunck optical flow (OF) method. From the high-speed coronary angiography (HSCA) images, the bolus of contrast could be visually tracked with ease as it traversed from the catheter tip through the artery. The imaging technique's high temporal resolution effectively minimized motion artifacts resulting from the heart's activity. The OF results of the contrast injection show velocities in the artery ranging from 20 - 40 cm/s. The results demonstrate the potential of 1000 fps HSCA in cardiovascular imaging. The combined high spatial and temporal resolution offered by this technique allows for the derivation of velocity profiles throughout the artery's structure, including regions distal and proximal to stenoses. This information can potentially be used to determine the need for stenoses treatment. Further investigations are warranted to expand our understanding of the applications of HSCA in cardiovascular research and clinical practice.

Cardiac Catheterization Laboratory Management of the Comatose Adult Patient With an Out-of-Hospital Cardiac Arrest: A Scientific Statement From the American Heart Association

Out-of-hospital cardiac arrest is a leading cause of death, accounting for ≈50% of all cardiovascular deaths. The prognosis of such individuals is poor, with <10% surviving to hospital discharge. Survival with a favorable neurologic outcome is highest among individuals who present with a witnessed shockable rhythm, received bystander cardiopulmonary resuscitation, achieve return of spontaneous circulation within 15 minutes of arrest, and have evidence of ST-segment elevation on initial ECG after return of spontaneous circulation. The cardiac catheterization laboratory plays an important role in the coordinated Chain of Survival for patients with out-of-hospital cardiac arrest. The catheterization laboratory can be used to provide diagnostic, therapeutic, and resuscitative support after sudden cardiac arrest from many different cardiac causes, but it has a unique importance in the treatment of cardiac arrest resulting from underlying coronary artery disease. Over the past few years, numerous trials have clarified the role of the cardiac catheterization laboratory in the management of resuscitated patients or those with ongoing cardiac arrest. This scientific statement provides an update on the contemporary approach to managing resuscitated patients or those with ongoing cardiac arrest.

The heart team: the multidisciplinary approach to coronary artery disease

The recommendation to employ a heart team to guide revascularization has persisted for over a decade. Despite evidence for improved adherence to guidelines, widespread adoption of the heart team approach has been limited. This review delves into the history of the guidelines endorsing the use of a heart team and the supporting data. Additionally, it outlines some attributes of a successful heart team, and how the heart team has been run at several large academic centers. Finally, it reviews some of the barriers to a heart team and future considerations.

Intravascular Imaging-Guided Versus Angiography-Guided Percutaneous Coronary Intervention: A Systematic Review and Meta-Analysis of Randomized Trials

BACKGROUND

Despite the initial evidence supporting the utility of intravascular imaging to guide percutaneous coronary intervention (PCI), adoption remains low. Recent new trial data have become available. An updated study-level meta-analysis comparing intravascular imaging to angiography to guide PCI was performed. This study aimed to evaluate the clinical outcomes of intravascular imaging-guided PCI compared with angiography-guided PCI.

METHODS AND RESULTS

A random-effects meta-analysis was performed on the basis of the intention-to-treat principle. The primary outcomes were major adverse cardiac events, cardiac death, and all-cause death. Mixed-effects meta-regression was performed to investigate the impact of complex PCI on the primary outcomes. A total of 16 trials with 7814 patients were included. The weighted mean follow-up duration was 28.8 months. Intravascular imaging led to a lower risk of major adverse cardiac events (relative risk [RR], 0.67 [95% CI, 0.55-0.82]; P<0.001), cardiac death (RR, 0.49 [95% CI, 0.34-0.71]; P<0.001), stent thrombosis (RR, 0.63 [95% CI, 0.40-0.99]; P=0.046), target-lesion revascularization (RR, 0.67 [95% CI, 0.49-0.91]; P=0.01), and target-vessel revascularization (RR, 0.60 [95% CI, 0.45-0.80]; P<0.001). In complex lesion subsets, the point estimate for imaging-guided PCI compared with angiography-guided PCI for all-cause death was a RR of 0.75 (95% CI, 0.55-1.02; P=0.07).

CONCLUSIONS

In patients undergoing PCI, intravascular imaging is associated with reductions in major adverse cardiac events, cardiac death, stent thrombosis, target-lesion revascularization, and target-vessel revascularization. The magnitude of benefit is large and consistent across all included studies. There may also be benefits in all-cause death, particularly in complex lesion subsets. These results support the use of intravascular imaging as standard of care and updates of clinical guidelines.

Triglyceride-glucose body mass index predicts prognosis in patients with ST-elevation myocardial infarction

Triglyceride glycemic-body mass index (TyG-BMI) is a simple and reliable surrogate for insulin resistance (IR). However, it is still unclear if TyG-BMI has any predictive value in patients having percutaneous coronary intervention (PCI) for ST-segment elevation myocardial infarction (STEMI). The purpose of this study was to examine the TyG-BMI index's prognostic significance and predictive power in patients with STEMI. The study comprised a total of 2648 consecutive STEMI patients who underwent PCI. The primary endpoint was the occurrence of major adverse cardiovascular events (MACE), defined as the combination of all-cause death, nonfatal myocardial infarction, nonfatal stroke, and coronary revascularization. The TyG-BMI index was formulated as ln [fasting triglycerides (mg/dL) × fasting plasma glucose (mg/dL)/2] × BMI. 193 patients in all experienced MACE over a median follow-up of 14.7 months. There was a statistically significant difference between the Kaplan-Meier survival curves for the TyG-BMI index tertiles (log-rank test, p = 0.019) for the cumulative incidence of MACE. The adjusted HRs for the incidence of MACE in the middle and highest quartiles of the TyG-BMI index compared with the lowest quartile were 1.37 (95% CI 0.92, 2.03) and 1.53 (95% CI 1.02, 2.29), respectively, in the fully adjusted Cox regression model. At six months, one year, and three years, the TyG-BMI area under the curve (AUC) for predicting MACE was 0.691, 0.666, and 0.637, respectively. Additionally, adding the TyG-BMI index to the risk prediction model enhanced outcome prediction. In STEMI patients undergoing PCI, TyG-BMI was independently linked to MACE. TyG-BMI could be a simple and solid way to assess MACE risk and prognosis.

Comparative efficacy of different Chinese patent medicines in preventing restenosis after percutaneous coronary intervention: a systematic review and Bayesian network meta-analysis of randomized clinical trials

Background: Chinese patent medicines (CMPs) have curative effectiveness in preventing coronary restenosis. However, the relative efficacy between different CPMs has not been sufficiently investigated. Methods: Randomized clinical trials were searched from electronic databases including PubMed, Web of Science, Cochrane Library, Embase, CNKI, VIP, WanFang, SinoMed, Chinese Clinical Trial Registry, and ClinicalTrials.gov. Bayesian network meta-analysis was performed to analyze CPMs' efficacy in preventing angiographic restenosis, recurrence angina, acute myocardial infarction, and target lesion revascularization after percutaneous coronary intervention. Results: This network meta-analysis included 47 trials with 5,077 patients evaluating 11 interventions. Regarding angiographic restenosis, the efficacy of CPMs (except Xuezhikang capsule) combined with standard treatment (Std) was superior to Std alone, and Guanxin Shutong capsule plus Std reduced the risk of angiographic restenosis by 76% (relative risk 0.24, 95% confidence interval 0.11-0.45, and very low to moderate certainty of evidence), most likely the best intervention. Fufang Danshen dripping pill combined with Std showed superiority over other interventions for relieving recurrence angina, which can reduce the risk by 83% (RR 0.17, 95% CI 0.04-0.51, very low to moderate certainty of evidence) compared to Std alone. In acute myocardial infarction after percutaneous coronary intervention, compared with Std alone, Danhong injection plus Std displayed a significant effect (RR 0.11, 95% CI 0.00-0.69, very low to moderate certainty of evidence) and was the best treatment probably. Chuanxiongqin tablet plus Std was the most effective treatment for reducing target lesion revascularization by 90% (RR 0.10, 95% CI 0.00-0.60, very low to moderate certainty of evidence) compared with Std alone. Conclusion: The results indicated that CPMs combined with Std reduced the risk of coronary restenosis after percutaneous coronary intervention. However, the results should be interpreted cautiously due to significant data limitations.

Cost-Effectiveness of Fractional Flow Reserve-Guided Treatment for Acute Myocardial Infarction and Multivessel Disease: A Prespecified Analysis of the FRAME-AMI Randomized Clinical Trial

Importance

Complete revascularization by non-infarct-related artery (IRA) percutaneous coronary intervention (PCI) in patients with acute myocardial infarction is standard practice to improve patient prognosis. However, it is unclear whether a fractional flow reserve (FFR)-guided or angiography-guided treatment strategy for non-IRA PCI would be more cost-effective.

Objective

To evaluate the cost-effectiveness of FFR-guided compared with angiography-guided PCI in patients with acute myocardial infarction and multivessel disease.

Design, Setting, and Participants

In this prespecified cost-effectiveness analysis of the FRAME-AMI randomized clinical trial, patients were randomly allocated to either FFR-guided or angiography-guided PCI for non-IRA lesions between August 19, 2016, and December 24, 2020. Patients were aged 19 years or older, had ST-segment elevation myocardial infarction (STEMI) or non-STEMI and underwent successful primary or urgent PCI, and had at least 1 non-IRA lesion (diameter stenosis >50% in a major epicardial coronary artery or major side branch with a vessel diameter of ≥2.0 mm). Data analysis was performed on August 27, 2023.

Intervention

Fractional flow reserve-guided vs angiography-guided PCI for non-IRA lesions.

Main Outcomes and Measures

The model simulated death, myocardial infarction, and repeat revascularization. Future medical costs and benefits were discounted by 4.5% per year. The main outcomes were quality-adjusted life-years (QALYs), direct medical costs, incremental cost-effectiveness ratio (ICER), and incremental net monetary benefit (INB) of FFR-guided PCI compared with angiography-guided PCI. State-transition Markov models were applied to the Korean, US, and European health care systems using medical cost (presented in US dollars), utilities data, and transition probabilities from meta-analysis of previous trials.

Results

The FRAME-AMI trial randomized 562 patients, with a mean (SD) age of 63.3 (11.4) years. Most patients were men (474 [84.3%]). Fractional flow reserve-guided PCI increased QALYs by 0.06 compared with angiography-guided PCI. The total cumulative cost per patient was estimated as $1208 less for FFR-guided compared with angiography-guided PCI. The ICER was -$19 484 and the INB was $3378, indicating that FFR-guided PCI was more cost-effective for patients with acute myocardial infarction and multivessel disease. Probabilistic sensitivity analysis showed consistent results and the likelihood iteration of cost-effectiveness in FFR-guided PCI was 97%. When transition probabilities from the pairwise meta-analysis of the FLOWER-MI and FRAME-AMI trials were used, FFR-guided PCI was more cost-effective than angiography-guided PCI in the Korean, US, and European health care systems, with an INB of $3910, $8557, and $2210, respectively. In probabilistic sensitivity analysis, the likelihood iteration of cost-effectiveness with FFR-guided PCI was 85%, 82%, and 31% for the Korean, US, and European health care systems, respectively.

Conclusions and Relevance

This cost-effectiveness analysis suggests that FFR-guided PCI for non-IRA lesions saved medical costs and increased quality of life better than angiography-guided PCI for patients with acute myocardial infarction and multivessel disease. Fractional flow reserve-guided PCI should be considered in determining the treatment strategy for non-IRA stenoses in these patients.

Trial Registration

ClinicalTrials.gov Identifier: NCT02715518.

2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Atrial Fibrillation: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines

AIM

The "2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Atrial Fibrillation" provides recommendations to guide clinicians in the treatment of patients with atrial fibrillation.

METHODS

A comprehensive literature search was conducted from May 12, 2022, to November 3, 2022, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Library, the Agency for Healthcare Research and Quality, and other selected databases relevant to this guideline. Additional relevant studies, published through November 2022, during the guideline writing process, were also considered by the writing committee and added to the evidence tables, where appropriate.

STRUCTURE

Atrial fibrillation is the most sustained common arrhythmia, and its incidence and prevalence are increasing in the United States and globally. Recommendations from the "2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation" and the "2019 AHA/ACC/HRS Focused Update of the 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation" have been updated with new evidence to guide clinicians. In addition, new recommendations addressing atrial fibrillation and thromboembolic risk assessment, anticoagulation, left atrial appendage occlusion, atrial fibrillation catheter or surgical ablation, and risk factor modification and atrial fibrillation prevention have been developed.

Angiographic Severity of the Nonculprit Lesion and the Efficacy of Fractional Flow Reserve-Guided Complete Revascularization in Patients With AMI: FRAME-AMI Substudy

BACKGROUND

The benefit of fractional flow reserve (FFR)-guided percutaneous coronary intervention (PCI) for noninfarct-related artery (IRA) lesions with angiographically severe stenosis in patients with acute myocardial infarction is unclear.

METHODS

Among 562 patients from the FRAME-AMI trial (Fractional Flow Reserve Versus Angiography-Guided Strategy for Management of Non-Infraction Related Artery Stenosis in Patients With Acute Myocardial Infarction) who were randomly allocated into either FFR-guided or angiography-guided PCI for non-IRA lesions, the current study evaluated the relationship between non-IRA stenosis measured by quantitative coronary angiography (QCA) and the efficacy of FFR-guided PCI. The incidence of the primary end point (death, myocardial infarction, or repeat revascularization) was compared between FFR- and angiography-guided PCI according to non-IRA stenosis severity (QCA stenosis ≥70% or <70%).

RESULTS

A total of 562 patients were assigned to FFR-guided (n=284) versus angiography-guided PCI (n=278). At a median follow-up of 3.5 years, the primary end point occurred in 14 of 181 patients with FFR-guided PCI and 31 of 197 patients with angiography-guided PCI among patients with QCA stenosis ≥70% (8.5% versus 19.2%; hazard ratio, 0.41 [95% CI, 0.22-0.80]; P=0.008), while occurred in 4 of 103 patients with FFR-guided PCI and 9 of 81 patients with angiography-guided PCI among those with QCA stenosis <70% (3.9% versus 11.1%; P=0.315). There was no significant interaction between treatment strategy and non-IRA stenosis severity (P for interaction=0.636). FFR-guided PCI was associated with the reduction of death and myocardial infarction in both patients with QCA stenosis ≥70% (6.7% versus 15.1%; P=0.008) and those with QCA stenosis <70% (1.0% versus 9.6%; P=0.042) compared with angiography-guided PCI.

CONCLUSIONS

In patients with acute myocardial infarction and multivessel disease, FFR-guided PCI tended to have a lower risk of primary end point than angiography-guided PCI regardless of non-IRA stenosis severity without significant interaction.

REGISTRATION

URL: https://www.clinicaltrials.gov; Unique identifier: NCT02715518.

Critical Analysis of Thrombocytopenia Associated With Glycoprotein IIb/IIIa Inhibitors and Potential Role of Zalunfiban, a Novel Small Molecule Glycoprotein Inhibitor, in Understanding the Mechanism(s)

Thrombocytopenia is a rare but serious complication of the intravenous glycoprotein IIb/IIIa (GPIIb/IIIa; integrin αIIbβ3) receptor inhibitors (GPIs), abciximab, eptifibatide, and tirofiban. The thrombocytopenia ranges from mild (50 000-100 000 platelets/μL), to severe (20 000 to <50 000/μL), to profound (<20 000/μL). Profound thrombocytopenia appears to occur in <1% of patients receiving their first course of therapy. Thrombocytopenia can be either acute (<24 hours) or delayed (up to ~14 days). Both hemorrhagic and thrombotic complications have been reported in association with thrombocytopenia. Diagnosis requires exclusion of pseudothrombocytopenia and heparin-induced thrombocytopenia. Therapy based on the severity of thrombocytopenia and symptoms may include drug withdrawals and treatment with steroids, intravenous IgG, and platelet transfusions. Abciximab-associated thrombocytopenia is most common and due to either preformed antibodies or antibodies induced in response to abciximab (delayed). Readministration of abciximab is associated with increased risk of thrombocytopenia. Evidence also supports an immune basis for thrombocytopenia associated with the 2 small molecule GPIs. The latter bind αIIbβ3 like the natural ligands and thus induce the receptor to undergo major conformational changes that potentially create neoepitopes. Thrombocytopenia associated with these drugs is also immune-mediated, with antibodies recognizing the αIIbβ3 receptor only in the presence of the drug. It is unclear whether the antibody binding depends on the conformational change and whether the drug contributes directly to the epitope. Zalunfiban, a second-generation subcutaneous small molecule GPI, does not induce the conformational changes; therefore, data from studies of zalunfiban will provide information on the contribution of the conformational changes to the development of GPI-associated thrombocytopenia.

Evidence-based Management of Left Main Coronary Artery Disease

Left main coronary artery disease (LMCAD) is associated with high morbidity and mortality due to the large myocardial mass at risk. Although medical treatment may be an option in selected low-risk patients, revascularisation is recommended to improve survival in the majority of patients presenting with a significant left main stenosis. In the past decade, multiple randomised clinical trials and meta-analyses have compared coronary artery bypass grafting surgery (CABG) versus percutaneous coronary intervention (PCI), finding controversial results. The strategy for LMCAD revascularisation is still challenging. Coronary anatomy complexity, clinical features and patient preferences are key elements to be considered by the heart team. The current guidelines define CABG as standard therapy, but the continuous improvements in PCI techniques, the use of intracoronary imaging and functional assessment make PCI a feasible alternative in selected patients, particularly in those with comorbidities and contraindications to CABG. This review analyses the most important studies comparing CABG versus PCI in patients with LMCAD.

The effect of cardiac rehabilitation on cardiopulmonary function after coronary artery bypass grafting: A systematic review and meta-analysis

We carried out a meta-analysis on the effect of cardiac rehabilitation (CR) on cardiopulmonary function after coronary artery bypass grafting (CABG). Four databases were searched for studies comparing CR with control. A random-effects model was used to pool mean difference (MD). The meta-analysis showed an increase in peak oxygen consumption (peak VO2) (MD = 1.93 mL/kg/min, p = 0.0006), and 6-min walk distance (6MWD) (MD = 59.21 m, p < 0.00001), and a decrease in resting heart rate (resting HR) (MD = 5.68 bpm, p < 0.0001) in the CR group. The subgroup analysis revealed aerobic exercise could further improve resting HR and peak HR, and physical/combination with aerobic exercise could further increase 6MWD. The improvement of peak VO2, workload, resting HR, peak HR, and 6MWD regarding CR performed within one week after CABG is greater than that one week after CABG. CR after CABG can improve the cardiopulmonary function, which is reflected by the improvement of peak VO2, 6MWD, and resting HR.

Drug-coated balloons versus drug-eluting stents in patients with acute myocardial infarction undergoing percutaneous coronary intervention: an updated meta-analysis with trial sequential analysis

BACKGROUND

Drug-coated balloons (DCBs) are an established strategy for coronary artery disease. However, the new generation drug-eluting stent (DES) is recommended for patients with Acute myocardial infarction (AMI) for coronary artery revascularization. Our aim is to provide a comprehensive appraisal of the efficacy of DCBs in patients with AMI undergoing PCI.

METHODS

We searched the WOS, PubMed, Scopus, and Cochrane CENTRAL till March 2023, for studies that compared DCBs versus DES in patients with AMI undergoing PCI. We used a random-effects model to compare major adverse cardiac events (MACE), cardiac death, all-cause death, myocardial infarction, target lesion revascularization (TLR), stent thrombosis, Late lumen Loss (LLL), and minimum lumen diameter (MLD) between the two groups.

RESULTS

Thirteen studies comprising 2644 patients were included. The pooled OR showed non-inferiority of DCB over DES in terms of MACE (OR = 0.89, 95% CI [0.57 to 1.40], p = 0.63). When we defined MACE as a composite of cardiac death, MI, and TLR; the pooled OR favored DCB over DES (OR = 0.50, 95% CI [0.28 to 0.9], p = 0.02). Moreover, DCB was not inferior to DES in terms of all-cause mortality (OR = 0.88, 95% CI: 0.43 to 1.8, p = 0.73), cardiac mortality, (OR = 0.59, 95% CI: 0.22 to 1.56, p = 0.29), MI (OR = 0.88, 95% CI: 0.34 to 2.29, p = 0.79), stent thrombosis (OR = 1.21, 95% CI: 0.35 to 4.23, p = 0.76), TLR (OR = 0.9, 95% CI: 0.43 to 1.93, p = 0.8), LLL (MD = -0.6, 95% CI: -0.3 to 0.19, p = 0.64), or MLD (MD = -0.4, 95% CI: -0.33 to 0.25, p = 0.76).

CONCLUSION

Our meta-analysis indicated that DCB intervention was not inferior to DES in the PCI setting in patients with AMI, and can be recommended as a feasible strategy in AMI.

PROSPERO REGISTRATION

CRD42023412757.