Comparison of coronary-artery bypass surgery and stenting for the treatment of multivessel disease

Prognostic significance of baseline low-density lipoprotein cholesterol in patients undergoing coronary revascularization; a report from the CREDO-Kyoto registry

BACKGROUND

The impact of very low baseline levels of low-density lipoprotein cholesterol (LDL-C) on patients with coronary artery disease remains unclear.

METHOD

We enrolled 39,439 patients of the pooled population from the CREDO-Kyoto registries Cohorts 1, 2, and 3. The study population consisted of 33,133 patients who had undergone their first coronary revascularization. We assessed the risk for mortality and cardiovascular events according to quintiles of the baseline LDL-C levels.

RESULTS

Patients in the very low LDL-C quintile (<85 mg/dL) had more comorbidities than those in the other quintiles. Lower LDL-C levels were strongly associated with anemia, thrombocytopenia, and end-stage renal disease. The cumulative 4-year incidence of all-cause death increased as LDL-C levels decreased (very low: 19.4 %, low: 14.5 %, intermediate: 11.1 %, high: 10.0 %, and very high: 9.2 %; p < 0.001), which was driven by both the early and late events. After adjusting for baseline characteristics, the adjusted risks of the very low and low LDL-C quintiles relative to the intermediate LDL-C quintile remained significant for all-cause death (very low: HR 1.29, 95 % CI 1.16-1.44, p < 0.001; low: HR 1.15, 95 % CI 1.03-1.29, p = 0.01). The excess adjusted risks of the lowest LDL-C quintile relative to the intermediate LDL-C quintile were significant for clinical outcomes such as cardiovascular death (HR 1.17, 95 % CI 1.01-1.35), non-cardiovascular death (HR 1.35, 95 % CI 1.15-1.60), sudden death (HR 1.44, 95 % CI 1.01-2.06), and heart failure admission (HR 1.11 95 % CI 1.01-1.22), while there was no excess risk for the lowest LDL-C quintile relative to the intermediate LDL-C quintile for myocardial infarction and stroke.

CONCLUSIONS

Lower baseline LDL-C levels were associated with more comorbidities and a significantly higher risk of death, regardless of cardiovascular or non-cardiovascular causes, in patients who underwent coronary revascularization.

Expanding revascularization trials to women and underserved minorities and shifting to patient-centered outcomes: RECHARGE trials program

PURPOSE OF REVIEW

We review the limited available evidence informing coronary revascularization decisions in women and minorities, and introduce the RECHARGE trial program, which consists of two separate but integrated parallel multicenter, randomized trials comparing coronary artery bypass grafting (CABG) to percutaneous coronary intervention (PCI), one exclusively enrolling women (RECHARGE:Women) and one exclusively enrolling Black or Hispanic patients (RECHARGE:Minorities).

RECENT FINDINGS

The extensive evidence base supporting coronary revascularization suffers from under-representation of women, minorities and minoritized populations, and the use of heterogeneous primary composite outcomes whose components have varying strengths of association with prognosis and quality-of-life (QOL). In RECHARGE, participants will be followed for up to 10 years, with QOL assessments at baseline, 30 days, 3 months, every 6 months for 3 years, and annually thereafter. The primary endpoint is the hierarchical composite of time to all-cause mortality, time-averaged change from baseline in the physical component of the SF-12v2 physical summary score, and time-averaged change from baseline in the mental component of the SF12v2 summary score, evaluated using a win ratio. Independently adjudicated major adverse cardiovascular and noncardiovascular events and disease-specific QoL will be secondary endpoints.

SUMMARY

The RECHARGE trials are the first revascularization trials to enroll exclusively women and minority patients and to use patient-centered outcomes as their primary outcome.

Outcomes of quantitative flow ratio-based functional incomplete revascularization after coronary artery bypass grafting surgery

OBJECTIVE

Quantitative flow ratio is a novel functional assessment tool of coronary diseases. Whether quantitative flow ratio could improve the outcomes of coronary artery bypass grafting is undetermined. This study aimed to investigate the association between the quantitative flow ratio based functional incomplete revascularization and the outcomes after coronary artery bypass grafting surgery.

METHODS

The quantitative flow ratio assessment was retrospectively performed in patients undergoing coronary artery bypass grafting surgery in the PATENCY trial. The anatomic complete revascularization denoted revascularizing each territory with stenosis greater than 50% evaluated by angiography. The functional complete revascularization was defined as grafting all vessels with a quantitative flow ratio 0.80 or less. The primary end point was the 12-month composite major adverse cardiac or cerebral vascular events.

RESULTS

A total of 2024 patients with available quantitative flow ratio values were included. Functional complete revascularization was achieved in 1846 patients (91.2%), and 1600 received anatomic complete revascularization (79.1%). Both the functional incomplete revascularization and anatomic incomplete revascularization groups were associated with significantly increased risks of 12-month major adverse cardiac or cerebral vascular events (functional: hazard ratio, 2.91; 95% confidence interval, 1.56 to 5.43; P = .001; anatomic: hazard ratio, 2.82; 95% confidence interval, 1.54 to 5.16; P = .001). Additionally, for the subgroup of patients (n = 246) receiving anatomic incomplete revascularization but judged as functional complete revascularization by quantitative flow ratio, the risk of the 12-month major adverse cardiac or cerebral vascular events was not significantly increased (adjusted hazard ratio, 1.36; 95% confidence interval, 0.71-2.60; P = .35).

CONCLUSIONS

Both the functional incomplete revascularization and anatomic incomplete revascularization were associated with increased risks of 12-month major adverse cardiac or cerebral vascular events after coronary artery bypass grafting surgery. The quantitative flow ratio can serve as a supplementary tool for the decision-making of surgical revascularization.

Intravascular ultrasound-guided versus angiography-guided percutaneous coronary intervention in unprotected left main coronary artery disease: A systematic review

BACKGROUND

Significant unprotected left main coronary artery (ULMCA) disease is encountered in approximately 5 % of patients undergoing diagnostic coronary angiography. Intravascular ultrasound (IVUS) overcomes many of the known limitations of angiography and improves outcomes of patients undergoing percutaneous coronary interventions (PCI) in stable or complex coronary artery disease. The aim of this systematic review is to evaluate the evidence on IVUS-guidance versus angiography-guidance in ULMCA PCI, highlighting the chronological frequencies of event rates in line with the maturation of PCI technique and devices over time.

METHODS

A comprehensive systematic search in Medline was performed to identify all studies that had assessed the effect of IVUS-guided versus angiography-guided ULMCA PCI on various primary and secondary endpoints.

RESULTS

Seventeen studies (2 randomized, 10 non-randomized and 5 meta-analyses) were included in this systematic review.

CONCLUSIONS

This systematic review on IVUS-guided versus angiography-guided PCI in patients with significant ULMCA disease strongly supports the hypothesis that IVUS-guided PCI is associated with a significant reduction in major adverse cardiac events composites, all-cause death, cardiac death, myocardial infarction and stent thrombosis. Ongoing, adequately powered trials will contribute significantly to the level of evidence.

Quality of Life After Percutaneous Coronary Intervention Versus Coronary Artery Bypass Grafting

BACKGROUND

Differences in quality of life (QoL) after coronary artery bypass grafting (CABG) compared with percutaneous coronary intervention (PCI) are not well characterized. We aimed to compare the short- and long-term effects of CABG versus PCI on QoL.

METHODS AND RESULTS

We performed a systematic review and meta-analysis of randomized controlled trials comparing CABG versus PCI using the Seattle Angina Questionnaire (SAQ)-Angina Frequency, SAQ-QoL, SAQ-Physical Limitations, EuroQoL-5D, and Short-Form Questionnaire. We calculated mean changes within each group from baseline to 1, 6, 12, and 36 to 60 months (latest follow-up) and the weighted mean differences between groups using inverse-variance methods. A total of 10 760 patients were enrolled in 5 trials. From baseline to 12 months and 36 to 60 months, the mean change in SAQ-Angina Frequency was >22 points (95% CI, 21.0-25.6) after both PCI and CABG. The mean difference in SAQ-Angina Frequency was similar between procedures at 1 month and at 36 to 60 months but favored CABG at 12 months (1.97 [95% CI, 0.68-3.26]). SAQ-QoL favored PCI at 1 month (-2.92 [95% CI, -4.66 to -1.18]) and CABG at 6 (2.50 [95% CI, 1.02-3.97]), 12 (3.30 [95% CI, 1.78-4.82]), and 36 to 60 months (3.17 [95% CI, 0.54 5.80). SAQ-Physical Limitations (-12.61 [95% CI, -16.16 to -9.06]) and EuroQoL-5D (-0.07 [95% CI, -0.08 to -0.07) favored PCI at 1 month. Short-Form Questionnaire-Physical Component favored CABG at 12 months (1.18 [95% CI, 0.46-1.90]).

CONCLUSIONS

Both PCI and CABG improved long-term disease-specific and generic QoL.

Impact of coronary artery bypass grafting surgery on the chorioretinal biomicroscopic characteristics

BACKGROUND

Most patients with cardiovascular disorders suffer from coronary artery diseases, which can be treated successfully using coronary artery bypass grafting (CABG). One of the unpleasant events following CABG is postoperative vision loss (POVL). Vulnerability of retinal vessels to hemodynamic changes, an expectable event following CABG, may contribute to the development of POVL, which might be associated with the changes in the choroidal and retinal structures.

AIM

To investigate postoperative changes in chorioretinal and peripapillary nerve fiber layer (NFL) thickness, and progression of diabetic and hypertensive retinopathy after CABG.

METHODS

In this prospective, cross-sectional study, 49 eyes in 25 candidates for CABG underwent both ophthalmic and cardiovascular examinations within 6 mo prior to and 9 mo after surgery.

RESULTS

Among the study participants, 56% were male with a mean age of 62.84 years ± 10.49 years (range 33-80 years). Diabetes mellitus was observed in eight participants (32%). None of the patients suffered from postoperative anterior or posterior ischemic optic neuropathy, central retinal artery occlusion, and cortical blindness. The mean value of the preoperative best corrected visual acuity was 0.11 ± 0.10 logMAR (range, 0-0.4), which worsened to 0.15 ± 0.08 logMAR (range, 0-0.4) after CABG (P = 0.031). No significant difference was observed between the pre- and postsurgical choroidal (P = 0.853) and macular (P = 0.507) thickness, NFL thickness in the subfoveal (P > 0.999) and peripapillary areas (P = 0.659), as well as the severity of diabetic and hypertensive retinopathy.

CONCLUSION

CABG may reduce visual acuity without affecting ocular structures. Postoperative vision reduction might be attributable to molecular or cellular variations, changes in visual pathway function, or central nervous system.

Effects of Long-Term Carvedilol Therapy in Patients With ST-Segment Elevation Myocardial Infarction and Mildly Reduced Left Ventricular Ejection Fraction

The benefits of long-term oral β-blocker therapy in patients with ST-segment elevation myocardial infarction (STEMI) with mildly reduced left ventricular ejection fraction (LVEF; ≥40%) are still unknown. We sought to evaluate the efficacy of β-blocker therapy in patients with STEMI with mildly reduced LVEF. In the CAPITAL-RCT (Carvedilol Post-Intervention Long-Term Administration in Large-Scale Randomized Controlled Trial), patients with STEMI with successful percutaneous coronary intervention with an LVEF of ≥40% were randomly assigned to carvedilol or no β-blocker therapy. Among 794 patients, 280 patients had an LVEF of <55% at baseline (mildly reduced LVEF stratum), whereas 514 patients had an LVEF of ≥55% at baseline (normal LVEF stratum). The primary end point was a composite of all-cause death, myocardial infarction, hospitalization for acute coronary syndrome, and hospitalization for heart failure, and the secondary end point was a cardiac composite outcome: a composite of cardiac death, myocardial infarction, and hospitalization for heart failure. The median follow-up period was 3.7 years. The lower risk of carvedilol therapy relative to no β-blocker therapy was not significant for the primary end point in either the mildly reduced or normal LVEF strata. However, it was significant for the cardiac composite end point in the mildly reduced LVEF stratum (0.82/100 person-years vs 2.59/100 person-years, hazard ratio 0.32 [0.10 to 0.99], p = 0.047) but not in the normal LVEF stratum (1.48/100 person-years vs 1.06/100 person-years, hazard ratio 1.39 [0.62 to 3.13], p = 0.43, p for interaction = 0.04). In conclusion, long-term carvedilol therapy in patients with STEMI with primary percutaneous coronary intervention might be beneficial for preventing cardiac-related events in those with a mildly reduced LVEF.

Impact of high intensity interval and moderate continuous training on plasma ratios of ProBNP1-108/BNP1-32 and NT-pro-BNP1-76/BNP1-32 after coronary artery bypass grafting surgery

Background: ProBNP1-108/BNP1-32, and NT-pro-BNP1-76/BNP1-32 ratios are significant indices for predicting complications after coronary artery bypass grafting (CABG) surgery. However, the effect of aerobic training types on these biomarkers has not been fully understood. So, the current study aimed to determine the impact of aerobic interval and continuous training programs on plasma ratios of ProBNP1-108/BNP1-32 and NT-pro-BNP1-76/BNP1-32 after coronary artery bypass grafting surgery. Method: 36 patients were selected purposive (27 men and 9 women with mean of age 60.32 ± 5.81 years, height 164.64 ± 9.25 cm, weight 73.86 ± 14.23 kg, fat 32.30 ± 4.28, SBP 142.67 ± 6.49, DBP 84.5 ± 5.16 mmHg in seated position at rest situation and functional capacity of 7.08 ± 2.49 METs) and then divided randomly into three groups: control (C) group (without training program) moderate continuous training (MCT) and high intensity interval training (HIIT) (exercise training program was performed 3 days/week for 8 weeks) with intensities 65%-80% and 80%-95% of reserve heart rate in order. Blood samples were taken 48 h before the first session and 48 h after the last training session to measure the plasma levels of ProBNP1-108, corin enzyme, BNP1-32, and NT-pro-BNP1-76 using the enzyme-linked immunosorbent assay (ELISA) technique. Wilcoxin and kruskal wallis tests were used for analyzing data. Results: The plasma corin enzyme was increased, and the ratios of proBNP1-108/BNP1-32 and NT-pro-BNP1-76/BNP1-32 were reduced in both training groups in compared with control group (p = 0.004, p = 0000, p = 0.016, p = 0.003, p = 0.009, and p = 0.016) when there was no significant difference was found between training groups (p = 0.074, p = 450, and p = 0.295). Conclusion: Both high intensity interval training and moderate continuous training in compared with inactivity have positive effects on ratios of ProBNP1-108/BNP1-32, NT-pro-BNP1-76/BNP1-32 and could be effective to promote the health of coronary arteries and prevention of HF in post-CABG patients.

Cost-effectiveness analysis of coronary arteries bypass grafting (CABG) and percutaneous coronary intervention (PCI) through drug stent in iran: a comparative study

BACKGROUND

Cost-effectiveness analysis plays a key role in evaluating health systems and services. Coronary artery disease is one of the primary health concerns worldwide. This study sought to compare the cost-effectiveness of Coronary Arteries Bypass Grafting (CABG) and Percutaneous Coronary Intervention (PCI) through drug stent using Quality-Adjusted Life Years (QALY) index.

METHODS

This is a cohort study involving all patients undergoing CABG and PCI through drug stent in south of Iran. A total of 410 patients were randomly selected to be included in the study. Data were gathered using SF-36, SAQ and a form for cost data from the patients' perspective. The data were analyzed descriptively and inferentially. Considering the analysis of cost-effectiveness, Markov Model was initially developed using TreeAge Pro 2020. Both deterministic and probabilistic sensitivity analyses were performed.

RESULTS

Compared with the group treated with PCI, the total cost of interventions was higher in the CABG group ($102,103.8 vs $71,401.22) and the cost of lost productivity ($20,228.68 vs $7632.11), while the cost of hospitalization was lower in CABG ($67,567.1 vs $49,660.97). The cost of hotel stay and travel ($6967.82 vs $2520.12) and the cost of medication ($7340.18 vs $11,588.01) was lower in CABG. From the patients' perspective and SAQ instrument, CABG was cost-saving, with a reduction of $16,581 for every increase in effectiveness. Based on patients' perspective and SF-36 instrument, CABG was cost-saving, with a reduction of $34,543 for every increase in effectiveness.

CONCLUSION

In the same indications, CABG intervention leads to more resource savings.

Sensors-based monitoring and treatment approaches for in-stent restenosis

Cardiovascular disease (CVD) can progressively narrow arteries due to plaque accumulation on the inner walls of the blood vessels, which results in an obstructed blood flow, leading to heart attack, stroke, and even death if the obstruction is severe. A popular treatment for the disease is to use an intravascular mechanical device called the stent to achieve an immediate restoration of blood flow. However, the physical stimulation induced by the stent expansion can cause inflammation of the vessel tissue. As one of the most common post-stenting complications, re-narrowing of the vessel is the main pathology that leads to in-stent restenosis (ISR), induced by the excess growth of the tissue over the deployed stent. The ISR is widely recognized as a significant cause of death globally if early symptoms are not detected. Hence, monitoring and early diagnosis indeed matter when it comes to treatment. The latest technologies for monitoring and treatments of ISR were reviewed in this work, and the potential issues and suggestions related to the reported technologies were presented. The target of this review aims to positively prompt researchers to develop an advanced stent system in terms of its electromechanical performance, size, functional feature, feasibility, and reliability.

The Ongoing Saga of the Evolution of Percutaneous Coronary Intervention: From Balloon Angioplasty to Recent Innovations to Future Prospects

The advances in percutaneous coronary intervention (PCI) have been, above all, dependent on the work of pioneers in surgery, radiology, and interventional cardiology. From Grüntzig's first balloon angioplasty, PCI has expanded through technology development, improved protocols, and dissemination of best-practice techniques. We can nowadays treat more complex lesions in higher-risk patients with favourable results. Guide wires, balloon types and profiles, debulking techniques such as atherectomy or lithotripsy, stents, and scaffolds all represent evolutions that have allowed us to tackle complex lesions such as an unprotected left main coronary artery, complex bifurcations, or chronic total occlusions. Best-practice PCI, including physiology assessment, imaging, and optimal lesion preparation are now the gold standard when performing PCI for sound indications, and new technologies such as intravascular lithotripsy for lesion preparation, or artificial intelligence, are innovations in the steps of 4 decades of pioneers to improve patient care in interventional cardiology. In the present review, major innovations in PCI since the first balloon angioplasty and also uncertainties and obstacles inherent to such medical advances are described.

Modifiers of the Risk of Diabetes for Long-Term Outcomes After Coronary Revascularization: CREDO-Kyoto PCI/CABG Registry

BACKGROUND

Diabetes is a well-known risk factor for adverse outcomes after coronary revascularization.

OBJECTIVES

This study sought to determine high-risk subgroups in whom the excess risks of diabetes relative to nondiabetes are particularly prominent and thus may benefit from more aggressive interventions.

METHODS

The study population consisted of 39,427 patients (diabetes: n = 15,561; nondiabetes: n = 23,866) who underwent first percutaneous coronary intervention (n = 33,144) or coronary artery bypass graft (n = 6,283) in the pooled CREDO-Kyoto PCI/CABG (Coronary Revascularization Demonstrating Outcome Study in Kyoto Percutaneous Coronary Intervention/Coronary Artery Bypass Graft) registry. The primary outcome measure was major adverse cardiovascular and cerebral endpoints (MACCE), which was defined as a composite of all-cause death, myocardial infarction, and stroke.

RESULTS

With median follow-up of 5.6 years, diabetes was associated with significantly higher adjusted risks for MACCE. The excess adjusted risks of diabetes relative to nondiabetes for MACCE increased with younger age (≤64 years: adjusted HR: 1.30; 95% CI: 1.19-1.41; P < 0.001; 64-73 years: adjusted HR: 1.24; 95% CI: 1.16-1.33; P < 0.001; >73 years: adjusted HR: 1.17; 95% CI: 1.10-1.23; P < 0.001; P _interaction < 0.001), mainly driven by greater excess adjusted mortality risk of diabetes relative to nondiabetes in younger tertile. No significant interaction was observed between adjusted risk of diabetes relative to nondiabetes for MACCE and other subgroups such as sex, mode of revascularization, and clinical presentation of acute myocardial infarction.

CONCLUSIONS

The excess risk of diabetes relative to nondiabetes for MACCE was profound in the younger population. This observation suggests more aggressive interventions for secondary prevention in patients with diabetes might be particularly relevant in younger patients.

KANK4 Promotes Arteriogenesis by Potentiating VEGFR2 Signaling in a TALIN-1-Dependent Manner

BACKGROUND

Arteriogenesis plays a critical role in maintaining adequate tissue blood supply and is related to a favorable prognosis in arterial occlusive diseases. Strategies aimed at promoting arteriogenesis have thus far not been successful because the factors involved in arteriogenesis remain incompletely understood. Previous studies suggest that evolutionarily conserved KANK4 (KN motif and ankyrin repeat domain-containing proteins 4) might involve in vertebrate vessel development. However, how the KANK4 regulates vessel function remains unknown. We aim to determine the role of endothelial cell-specifically expressed KANK4 in arteriogenesis.

METHODS

The role of KANK4 in regulating arteriogenesis was evaluated using Kank4^-/- and KANK4^iECOE mice. Molecular mechanisms underlying KANK4-potentiated arteriogenesis were investigated by employing RNA transcriptomic profiling and mass spectrometry analysis.

RESULTS

By analyzing Kank4-EGFP reporter mice, we showed that KANK4 was specifically expressed in endothelial cells. In particular, KANK4 displayed a dynamic expression pattern from being ubiquitously expressed in all endothelial cells of the developing vasculature to being explicitly expressed in the endothelial cells of arterioles and arteries in matured vessels. In vitro microfluidic chip-based vascular morphology analysis and in vivo hindlimb ischemia assays using Kank4^-/- and KANK4^iECOE mice demonstrated that deletion of KANK4 impaired collateral artery growth and the recovery of blood perfusion, whereas KANK4 overexpression leads to increased vessel caliber and blood perfusion. Bulk RNA sequencing and Co-immunoprecipitation/mass spectrometry (Co-IP/MS) analysis identified that KANK4 promoted EC proliferation and collateral artery remodeling through coupling VEGFR2 (vascular endothelial growth factor receptor 2) to TALIN-1, which augmented the activation of the VEGFR2 signaling cascade.

CONCLUSIONS

This study reveals a novel role for KANK4 in arteriogenesis in response to ischemia. KANK4 links VEGFR2 to TALIN-1, resulting in enhanced VEGFR2 activation and increased EC proliferation, highlighting that KANK4 is a potential therapeutic target for promoting arteriogenesis for arterial occlusive diseases.

Bleeding Outcomes After Percutaneous Coronary Intervention in the Past Two Decades in Japan - From the CREDO-Kyoto Registry Cohort-2 and Cohort-3

BACKGROUND

Optimal intensity is unclear for P2Y12receptor blocker therapy after percutaneous coronary intervention (PCI) in real-world clinical practice.

METHODS AND RESULTS

From the CREDO-Kyoto Registry, the current study population consisted of 25,419 patients (Cohort-2: n=12,161 and Cohort-3: n=13,258) who underwent their first PCI. P2Y12receptor blocker therapies were reduced dose of ticlopidine (200 mg/day), and global dose of clopidogrel (75 mg/day) in 87.7% and 94.8% of patients in Cohort-2 and Cohort-3, respectively. Cumulative 3-year incidence of GUSTO moderate/severe bleeding was significantly higher in Cohort-3 than in Cohort-2 (12.1% and 9.0%, P<0.0001). After adjusting 17 demographic factors and 9 management factors potentially related to the bleeding events other than the type of P2Y12receptor blocker, the higher bleeding risk in Cohort-3 relative to Cohort-2 remained significant (hazard ratio (HR): 1.52 95% confidence interval (CI) 1.37-1.68, P<0.0001). Cohort-3 compared with Cohort-2 was not associated with lower adjusted risk for myocardial infarction/ischemic stroke (HR: 0.96, 95% CI: 0.87-1.06, P=0.44).

CONCLUSIONS

In this historical comparative study, Cohort-3 compared with Cohort-2 was associated with excess bleeding risk, which might be at least partly explained by the difference in P2Y12receptor blockers.

Ranolazine: a better understanding of pathophysiology and patient profile to guide treatment of chronic stable angina

Chronic stable angina pectoris, the most prevalent symptomatic manifestation of coronary artery disease, greatly impairs quality of life and is associated with an increased risk for adverse cardiovascular outcomes. Better understanding of the pathophysiologic mechanisms of myocardial ischemia permitted new therapeutic strategies to optimize the management of angina patients. Ideally, antianginal drug treatment should be tailored to individual patient's profile and chosen according to the pathophysiology, hemodynamic profile, adverse effects, potential drug interactions and comorbidities. In this respect, and because of its peculiar mechanism of action, ranolazine represents an alternative therapeutic approach in patients with chronic stable angina and may be considered the first choice in presence of comorbidities that difficult the use of traditional therapies.

Quality of life in patients with stable coronary artery disease submitted to percutaneous, surgical, and medical therapies: a cohort study

Background

Clinical, surgical, and percutaneous strategies similarly prevent major cardiovascular events in patients with stable coronary artery disease (CAD). The possibility that these strategies have differential effects on health-related quality of life (HRQoL) has been debated, particularly in patients treated outside clinical trials.

Methods

We assigned 454 patients diagnosed with CAD during an elective diagnostic coronary angiography to coronary artery bypass grafting (CABG), percutaneous coronary intervention (PCI), or optimal medical treatment (OMT), and followed them for an average of 5.2 ± 1.5 years. HRQoL was assessed using a validated Brazilian version of the 12-Item Short-Form Health Survey questionnaire. The association between therapeutic strategies and quality of life scores was tested using variance analysis and adjusted for confounders in a general linear model.

Results

There were no differences in the mental component summary scores in the follow-up evaluation by therapeutic strategies: 51.4, 53.7, and 52.3 for OMT, PCI, and CABG, respectively. Physical component summary scores were higher in the PCI group than the CABG and OMT groups (46.4 vs. 42.9 and 43.8, respectively); however, these differences were no longer different after adjustment for confounding variables.

Conclusion

In a long-term follow-up of patients with stable CAD, HRQoL did not differ in patients treated by medical, percutaneous, or surgical treatments.

Five-year outcomes after coronary artery bypass grafting and percutaneous coronary intervention in octogenarians with complex coronary artery disease

OBJECTIVE

We assessed the clinical effectiveness of coronary artery bypass grafting (CABG) in comparison with that of percutaneous coronary intervention (PCI) in octogenarians with triple-vessel disease (TVD) or left main coronary artery (LMCA) disease.

METHODS

From the CREDO-Kyoto registry cohort-2, 527 patients, who were ≥ 80 years of age and underwent the first coronary revascularization for TVD or LMCA disease, were divided into the CABG group (N = 151) and the PCI group (N = 376).

RESULTS

The median and interquartile range of patient's age was 82 (81-84) in the CABG group and 83 (81-85) in the PCI group (P = 0.10). Patients >  = 85 years of age accounted for 19% and 31% in the CABG and PCI groups, respectively (P = 0.01). The cumulative 5-year incidence of all-cause death was similar between CABG and PCI groups (35.8% vs. 42.9%, log-rank P = 0.18), while CABG showed a lower rate of the composite of cardiac death/MI than PCI (21.7% vs. 33.9%, log-rank P = 0.005). After adjusting for confounders, the lower risk of CABG relative to PCI was significant for all-cause death (HR 0.61, 95% CI 0.43-0.86, P = 0.005), any coronary revascularization (HR 0.25, 95% CI 0.14-0.43, P < 0.001) and the composite of cardiac death/MI (HR 0.52, 95% CI 0.32-0.85, P = 0.009).

CONCLUSIONS

CABG compared with PCI was associated with a lower adjusted risk for all-cause death, any coronary revascularization, and a composite of cardiac death/MI in very elderly patients with TVD or LMCA disease. CABG seemed an acceptable option for selected octogenarians with severe coronary artery disease.

Photon-Counting Computed Tomography for Coronary Stent Imaging: In Vitro Evaluation of 28 Coronary Stents

OBJECTIVES

The aim of this study was to assess in-stent lumen visibility and quantitative image characteristics of different coronary stents using a novel photon-counting detector (PCD) computed tomography (CT) system in comparison to a state-of-the-art energy-integrating detector (EID) CT scanner.

MATERIALS AND METHODS

In this in vitro phantom study, 28 different coronary stents ranging from 2.25 to 4.5 mm lumen diameter were expanded into plastic tubes filled with contrast agent. Stent-containing plastic tubes were positioned in a custom-made emulsion-filled phantom, which was inserted into an anthropomorphic phantom simulating a medium-sized patient. Computed tomography scans were acquired parallel to the scanners' z axis using a novel cadmium telluride-based PCD CT system (SOMATOM CountPlus; Siemens Healthcare GmbH, Forchheim Germany), operating in 2 different modes (standard-resolution mode [SR] and ultra-high-resolution [UHR] mode), and a latest generation dual-source EID CT system (SOMATOM Force; Siemens Healthcare GmbH, Forchheim). CTDIvol-matched images were reconstructed with comparable convolution kernels and using the same reconstruction parameters. In-stent lumen visibility (in %), increase in in-stent attenuation (expressed as Δ in-stent CT attenuation), and image noise (in Hounsfield unit) were manually measured. Parts of the image analysis (in-stent lumen visibility) were additionally performed in an automated way. Differences were tested using Wilcoxon signed rank test.

RESULTS

The best in-stent lumen visibility was achieved with the PCD-UHR mode and the lowest noise levels with the PCD-SR mode. The median in-stent lumen visibility was significantly higher (P < 0.001) with PCD (SR, 66.7%; interquartile range [IQR], 63.3-72.3; UHR, 68.9%; IQR, 64.4-74.4) compared with EID (65.4%; IQR, 62.2-70.4). The Δ in-stent CT attenuation was significantly lower for PCD in both SR (78 HU; IQR, 46-108; P = 0.024) and UHR (85 HU; IQR, 59-113; P = 0.006) compared with EID (108 HU; IQR, 85-126). Image noise was significantly lower (P < 0.001) for PCD-SR (21 HU; IQR, 21-21) compared with EID images (25 HU; IQR, 24-25.0).

CONCLUSIONS

The PCD provides superior in-stent lumen visibility and quantitative image characteristics when compared with conventional EID.

Real-world long-term outcomes based on three therapeutic strategies in very old patients with three-vessel disease

Background

There are relatively limited data regarding real-world outcomes in very old patients with three-vessel disease (3VD) receiving different therapeutic strategies. This study aimed to perform analysis of long-term clinical outcomes of medical therapy (MT), coronary artery bypass grafting (CABG), and percutaneous coronary intervention (PCI) in this population.

Methods

We included 711 patients aged ≥ 75 years from a prospective cohort of patients with 3VD. Consecutive enrollment of these patients began from April 2004 to February 2011 at Fu Wai Hospital. Patients were categorized into three groups (MT, n = 296; CABG, n = 129; PCI, n = 286) on the basis of different treatment strategies.

Results

During a median follow-up of 7.25 years, 262 deaths and 354 major adverse cardiac and cerebrovascular events (MACCE) occurred. Multivariate Cox analysis showed that the risk of cardiac death was significantly lower for CABG compared with PCI (adjusted hazard ratio [HR] = 0.475, 95% confidence interval [CI] 0.232–0.974, P = 0.042). Additionally, MACCE appeared to show a trend towards a better outcome for CABG (adjusted HR = 0.759, 95% CI 0.536–1.074, P = 0.119). Furthermore, CABG was significantly superior in terms of unplanned revascularization (adjusted HR = 0.279, 95% CI 0.079–0.982, P = 0.047) and myocardial infarction (adjusted HR = 0.196, 95% CI 0.043–0.892, P = 0.035). No significant difference in all-cause death between CABG and PCI was observed. MT had a higher risk of cardiac death than PCI (adjusted HR = 1.636, 95% CI 1.092–2.449, P = 0.017). Subgroup analysis showed that there was a significant interaction between treatment strategy (PCI vs. CABG) and sex for MACCE (P = 0.026), with a lower risk in men for CABG compared with that of PCI, but not in women.

Conclusions

CABG can be performed with reasonable results in very old patients with 3VD. Sex should be taken into consideration in therapeutic decision-making in this population.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12872-021-02067-6.

Ischemic and bleeding risk after complex percutaneous coronary intervention in patients with or without high bleeding risk

OBJECTIVES

To evaluate utility of the complex percutaneous coronary intervention (PCI) criteria in real-world practice.

BACKGROUND

Applicability of procedural complexity criteria for risk stratification has not been adequately evaluated in real-world practice.

METHODS

Among 13,087 patients undergoing first PCI in the CREDO-Kyoto registry cohort-2, the study population consisted of 7,871 patients after excluding patients with acute myocardial infarction and those without stent implantation. Complex PCI was defined as PCI, which fulfills at least one of the followings: three vessels treated, > = 3 stents implanted, > = 3 lesions treated, bifurcation with two stents, >60 mm total stent lengths, and target of chronic total occlusion.

RESULTS

The cumulative incidences of and adjusted risks for the primary ischemic (myocardial infarction/ischemic stroke), and bleeding (GUSTO moderate/severe) endpoints were significantly higher in patients with complex PCI (N = 2,777 [35%]) than in those with noncomplex PCI (N = 5,094 [65%]) (15.4% vs. 10.9%, log-rank p < .001; odds ratio (OR): 1.53, 95% confidence interval (CI): 1.31-1.79, p < .001, and 11.9% vs. 9.9%, log-rank p = .004; OR: 1.24, 95% CI: 1.05-1.46, p = .01). In the 30-day landmark analysis, the higher risks of patients with complex PCI for ischemic and major bleeding events were only seen within 30 days after PCI (ischemic; within 30 days: HR: 2.19, 95% CI: 1.79-2.69, p < .001; beyond 30 days: HR: 1.11, 95% CI: 0.92-1.34, p = .26, and bleeding; within 30 days: HR: 1.56, 95% CI: 1.13-2.16, p = .007; beyond 30 days: HR: 1.11, 95% CI: 0.94-1.31, p = .22).

CONCLUSIONS

Patients with complex PCI as compared with patients with noncomplex PCI had a higher risk for both ischemic and bleeding events mainly within 30 days after PCI.

Effects of Acute Coronary Syndrome and Stable Coronary Artery Disease on Bleeding and Ischemic Risk After Percutaneous Coronary Intervention

BACKGROUND

Data evaluating the effects of acute coronary syndrome (ACS) relative to stable coronary artery disease (CAD) on bleeding risk after percutaneous coronary intervention (PCI) are scarce.Methods and Results:From the CREDO-Kyoto Registry Cohort-3, 13,258 patients undergoing first PCI (5,521 ACS; 7,737 stable CAD) were identified. Patients were further stratified according to ACS presentation and Academic Research Consortium High Bleeding Risk (HBR): ACS/HBR: n=2,502; ACS/no-HBR: n=3,019; stable CAD/HBR: n=3,905; and stable CAD/no-HBR: n=3,832. The primary bleeding endpoint was Bleeding Academic Research Consortium 3/5 bleeding, whereas the primary ischemic endpoint was myocardial infarction (MI)/ischemic stroke. Compared with stable CAD, ACS was associated with a significantly higher adjusted risk for bleeding (hazard ratio [HR] 1.85; 95% confidence interval [CI] 1.68-2.03; P<0.0001), with a markedly higher risk within 30 days (HR 4.24; 95% CI 3.56-5.06; P<0.0001). Compared with the stable CAD/no-HBR group, the ACS/HBR, no-ACS/HBR, and ACS/no-HBR groups were associated with significantly higher adjusted risks for bleeding, with HRs of 3.05 (95% CI 2.64-3.54; P<0.0001), 1.89 (95% CI 1.66-2.15; P<0.0001), and 1.69 (95% CI 1.45-1.98; P<0.0001), respectively. There was no excess adjusted risk of the ACS relative to stable CAD group for MI/ischemic stroke (HR 1.07; 95% CI 0.94-1.22; P=0.33).

CONCLUSIONS

Bleeding risk after PCI depended on both ACS presentation and HBR, with a significant effect of ACS within 30 days.

Changes in demographics, clinical practices and long-term outcomes of patients with ST segment-elevation myocardial infarction who underwent coronary revascularisation in the past two decades: cohort study

OBJECTIVE

To evaluate changes in demographics, clinical practices and long-term clinical outcomes of patients with ST segment-elevation myocardial infarction (STEMI) before and beyond 2010.

DESIGN

Multicentre retrospective cohort study.

SETTING

The Coronary Revascularization Demonstrating Outcome Study in Kyoto (CREDO-Kyoto) AMI Registries Wave-1 (2005-2007, 26 centres) and Wave-2 (2011-2013, 22 centres).

PARTICIPANTS

9001 patients with STEMI who underwent coronary revascularisation (Wave-1: 4278 patients, Wave-2: 4723 patients).

PRIMARY AND SECONDARY OUTCOME MEASURES

The primary outcome was all-cause death at 3 years. The secondary outcomes were cardiovascular death, cardiac death, sudden cardiac death, non-cardiovascular death, non-cardiac death, myocardial infarction, definite stent thrombosis, stroke, hospitalisation for heart failure, major bleeding, target vessel revascularisation, ischaemia-driven target vessel revascularisation, any coronary revascularisation and any ischaemia-driven coronary revascularisation.

RESULTS

Patients in Wave-2 were older, more often had comorbidities and more often presented with cardiogenic shock than those in Wave-1. Patients in Wave-2 had shorter onset-to-balloon time and door-to-balloon time, were more frequently implanted drug-eluting stents, and received guideline-directed medication than those in Wave-1. The cumulative 3-year incidence of all-cause death was not significantly different between Wave-1 and Wave-2 (15.5% and 15.7%, p=0.77). The adjusted risk of all-cause death in Wave-2 relative to Wave-1 was not significant at 3 years (HR 0.92, 95% CI 0.83 to 1.03, p=0.14), but lower beyond 30 days (HR 0.86, 95% CI 0.75 to 0.98, p=0.03). The adjusted risks of Wave-2 relative to Wave-1 were significantly lower for definite stent thrombosis (HR 0.59, 95% CI 0.43 to 0.81, p=0.001) and for any coronary revascularisation (HR 0.75, 95% CI 0.69 to 0.81, p<0.001), but higher for major bleeding (HR 1.34, 95% CI 1.20 to 1.51, p=0.005).

CONCLUSIONS

We could not demonstrate improvement in 3-year mortality risk from Wave-1 to Wave-2, but we found reduction in mortality risk beyond 30 days. We also found risk reduction for definite stent thrombosis and any coronary revascularisation, but an increase in the risk of major bleeding from Wave-1 to Wave-2.

Long-term outcomes of patients undergoing coronary sinus reducer implantation - A multicenter study

BACKGROUND

Coronary sinus (CS) narrowing by reducer implantation has emerged as a safe and effective therapy for patients suffering from refractory angina. However, data regarding the clinical benefit of this treatment over time is lacking.

METHODS

Patients undergoing successful reducer implantation were enrolled prospectively to clinical registries at three medical centers. Those with more than 2-years of follow-up were included in the present analysis. Peri-procedural data, data regarding adverse events, and current evaluation of angina severity (Canadian Cardiovascular Society [CCS] class) were collected.

RESULTS

Overall, 99 consecutive patients (77% males, mean age 69.8 ± 9.4) with severe angina were enrolled between September 2010 and October 2017 and included in the present analysis. No procedure-related complications were recorded. During a median follow up time of 3.38 years (IQR 2.95-4.40), 15.1% of the patients died, 9% experienced myocardial infarction (MI) and 21% underwent percutaneous coronary intervention (PCI). Mean CCS class was 3.1 ± 0.5 at baseline, improved to 1.66 ± 0.8 at 1 year (p < .001), and remained low through 2-years and at last follow up (1.72 ± 0.8 and 1.71 ± 0.8, p > 0.5 for both, in comparison to 1 year). At baseline 91% of patients reported severe disabling angina (CCS class 3-4), at 1 year only 17.9% suffered from disabling angina, p < .001, and this portion remained low overtime (19% at last follow up).

CONCLUSION

Long-term mortality of patients undergoing reducer implantation is similar to that reported for patients with stable coronary artery disease. The previously reported short-term efficacy of the reducer, reflected by significant improvement of angina symptoms, is maintained over time.

Coronary revascularization in patients with stable coronary disease and diabetes mellitus

PURPOSE OF STUDY

Diabetes mellitus accelerates the development of atherosclerosis. Patients with diabetes mellitus have higher incidence and mortality rates from cardiovascular disease and undergo a disproportionately higher number of coronary interventions compared to the general population. Proper selection of treatment modalities is thus paramount. Treatment strategies include medical management and interventional approaches including coronary artery bypass graft (CABG) surgery and percutaneous coronary interventions (PCI). The purpose of this review is to assimilate emerging evidence comparing CABG to PCI in patients with diabetes and present an outlook on the latest advances in percutaneous interventions, in addition to the optimal medical therapies in patients with diabetes.

KEY METHODS

A systematic search of PubMed, Web of Science and EMBASE was performed to identify prospective, randomized trials comparing outcomes of CABG and PCI, and also PCI with different generations of stents used in patients with diabetes. Additional review of bibliography of selected studies was also performed.

MAIN CONCLUSIONS

Most of the trials discussed above demonstrate a survival advantage of CABG over PCI in patients with diabetes. However, recent advances in PCI technology are starting to challenge this narrative. Superior stent designs, use of specific drug-eluting stents, image-guided stent deployment, and the use of contemporary antiplatelet and lipid-lowering therapies are continuing to improve the PCI outcomes. Prospective data for such emerging interventional technologies in diabetes is however lacking currently and is the need of the hour.

Clinical outcomes of multivessel coronary artery disease patients revascularized by robot-assisted vs conventional standard coronary artery bypass graft surgeries in real-world practice

The treatment of patients with multivessel coronary artery disease (MVD) by coronary stenting (PCI) and the "gold standard" conventional coronary-artery bypass grafting (C-CABG) has been well explored in the literature. However, the clinical outcomes of robot-assisted CABG (R-CABG) vs C-CABG in MVD patients in real-world practice were unknown. We aimed to study the clinical outcomes of MVD patients who underwent R-CABG (robotic MIDCAB) and C-CABG at our institution between January 2005 and December 2013.A total of 516 MVD patients received CABG were recruited into this study. Among them, 281 patients received R-CABG and 235 patients underwent C-CABG. Patients in the R-CABG group were younger, and had fewer vessels with coronary artery disease (CAD), lower prevalence of chronic renal disease (CKD), higher left ventricular ejection fraction (LVEF), as well as lower Euro scores. The in-hospital and long-term mortalities were lower in the R-CABG group, but the incidences of target lesion revascularization (TLR), target vessel revascularization (TVR), myocardial infarction (MI), and stroke were not significantly different between the two groups. The long-term mortality was related to age, lower LVEF, and CKD, but not residual SYNTAX score, or completeness of revascularization. The revascularization modality (R-CABG vs C-CABG) was a borderline significantly independent predictor of long-term mortality (OR 1.76 [0.99-3.14], P = .055).Our study concluded that R-CABG, in comparison with C-CABG, for MVD carried out in younger patients involved fewer clinical complexities was associated with lower in-hospital and long-term mortalities in real-world practice. However, the long-term rates of TLR, TVR, MI, and stroke were similar. The long-term mortality was correlated with age, lower LVEF, and CKD, where R-CABG remained a borderline significant predictor after correcting for confounding factors. R-CABG could be an effective alternative to C-CABG for MVD patients with fewer clinical complexities in real-world practice.

Predictors of recurrent angina in patients with no need for secondary revascularization

BACKGROUND

Approximately 20% to 30% of patients with coronary artery disease (CAD) develop recurrent angina pectoris following successful and complete coronary revascularization utilizing percutaneous coronary intervention (PCI). We aim to investigate predictors of recurrent angina pectoris in patients who have undergone successful coronary revascularization using PCI, but on repeat coronary angiography have no need for secondary revascularization.

METHODS

The study comprised 3,837 patients with CAD, who were enrolled from January 2007 to June 2019. They had undergone successful PCI; some of them redeveloped angina pectoris within one year after the procedure, but on repeat coronary angiography had no need for revascularization. Thrombolysis in myocardial infarction (TIMI) frame count was used to evaluate the velocity of coronary blood in the follow-up angiogram. Multivariate logistic regression was used to investigate risk factors for recurrent angina pectoris. Similarly, predictors of recurrent angina according to the TIMI frame count were assessed using multivariate linear regression.

RESULTS

In this retrospective study, 53.5% of patients experienced recurrent angina pectoris. By multivariate logistic regression, the following characteristics were statistically identified as risk factors for recurrent angina pectoris: female sex, older age, current smoking, low-density lipoprotein cholesterol (LDL-C) ≥1.8 mmol/L, and an elevated TIMI frame count (P for all <0.05). Similarly, using multivariate linear regression, the statistical risk factors for TIMI frame count included: female sex, older age, diabetes, body mass index (BMI), post-procedural treatment without the inclusion of dual antiplatelet therapy.

CONCLUSIONS

Patient characteristics of female sex, older age, diabetes, and elevated BMI are associated with an increased TIMI frame count, coronary microcirculation dysfunction, and recurrent angina pectoris after initially successful PCI. In addition, current smoking and LDL-C ≥1.8 mmol/L are risk factors for recurrent angina pectoris. In contrast, the treatment with dual antiplatelet therapy is negatively correlated with a higher TIMI frame count and the risk of recurrent angina pectoris.

Application of the Modified High Bleeding Risk Criteria for Japanese Patients in an All-Comers Registry of Percutaneous Coronary Intervention - From the CREDO-Kyoto Registry Cohort-3

BACKGROUND

The prevalence of and expected bleeding event rate in patients with the Japanese version of high bleeding risk (J-HBR) criteria are currently unknown in real-world percutaneous coronary intervention (PCI) practice.Methods and Results:We applied the J-HBR criteria in the multicenter CREDO-Kyoto registry cohort-3 that enrolled 13,258 consecutive patients who underwent first PCI. The J-HBR criteria included Japanese-specific major criteria such as heart failure, low body weight, peripheral artery disease and frailty in addition to the Academic Research Consortium (ARC)-HBR criteria. There were 8,496 patients with J-HBR, and 4,762 patients without J-HBR. The J-HBR criteria identified a greater proportion of patients with HBR than did ARC-HBR (64% and 48%, respectively). Cumulative incidence of the Bleeding Academic Research Consortium (BARC) type 3 or 5 bleeding was significantly higher in the J-HBR group than in the no-HBR group (14.0% vs. 4.1% at 1 year; 23.1% vs. 8.4% at 5 years, P<0.0001). Cumulative 5-year incidence of BARC 3/5 bleeding was 25.1% in patients with ARC-HBR, and 23.1% in patients with J-HBR. Cumulative incidence of myocardial infarction or ischemic stroke was also significantly higher in the J-HBR group than in the no-HBR group (6.9% vs. 3.6% at 1 year; 13.2% vs. 7.1% at 5 years, P<0.0001).

CONCLUSIONS

The J-HBR criteria successfully identified those patients with very high bleeding risk after PCI, who represented 64% of patients in this all-comers registry.

Overall and Cause-Specific Mortality in Randomized Clinical Trials Comparing Percutaneous Interventions With Coronary Bypass Surgery: A Meta-analysis

IMPORTANCE

Mortality is a common outcome in trials comparing percutaneous coronary intervention (PCI) with coronary artery bypass grafting (CABG). Controversy exists regarding whether all-cause mortality or cardiac mortality is preferred as a study end point, because noncardiac mortality should be unrelated to the treatment.

OBJECTIVE

To evaluate the difference in all-cause and cause-specific mortality in randomized clinical trials (RCTs) comparing PCI with CABG for the treatment of patients with coronary artery disease.

DATA SOURCES

MEDLINE (1946 to the present), Embase (1974 to the present), and the Cochrane Library (1992 to the present) databases were searched on November 24, 2019. Reference lists of included articles were also searched, and additional studies were included if appropriate.

STUDY SELECTION

Articles were considered for inclusion if they were in English, were RCTs comparing PCI with drug-eluting or bare-metal stents and CABG for the treatment of coronary artery disease, and reported mortality and/or cause-specific mortality. Trials of PCI involving angioplasty without stenting were excluded. For each included trial, the publication with the longest follow-up duration for each outcome was selected.

DATA EXTRACTION AND SYNTHESIS

For data extraction, all studies were reviewed by 2 independent investigators, and disagreements were resolved by a third investigator in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses guideline. Data were pooled using fixed- and random-effects models.

MAIN OUTCOMES AND MEASURES

The primary outcomes were all-cause and cause-specific (cardiac vs noncardiac) mortality. Subgroup analyses were performed for PCI trials using drug-eluting vs bare-metal stents and for trials involving patients with left main disease.

RESULTS

Twenty-three unique trials were included involving 13 620 unique patients (6829 undergoing PCI and 6791 undergoing CABG; men, 39.9%-99.0% of study populations; mean age range, 60.0-71.0 years). The weighted mean (SD) follow-up was 5.3 (3.6) years. Compared with CABG, PCI was associated with a higher rate of all-cause (incidence rate ratio, 1.17; 95% CI, 1.05-1.29) and cardiac (incidence rate ratio, 1.24; 95% CI, 1.05-1.45) mortality but also noncardiac mortality (incidence rate ratio, 1.19; 95% CI, 1.00-1.41).

CONCLUSIONS AND RELEVANCE

Percutaneous coronary intervention was associated with higher all-cause, cardiac, and noncardiac mortality compared with CABG at 5 years. The significantly higher noncardiac mortality associated with PCI suggests that even noncardiac deaths after PCI may be procedure related and supports the use of all-cause mortality as the end point for myocardial revascularization trials.

The birth, decline, and contemporary re-emergence of endovascular brachytherapy for prevention of in-stent restenosis

Despite the advent of drug-eluting stents and dual antiplatelet therapy in the interventional management of cardiovascular disease, restenosis rates remain high with significant sequelae. Endovascular brachytherapy-popular in the 1990s and early 2000s-has recently resurfaced as a cost-effective treatment option. In this work, we outline the history of endovascular brachytherapy starting with its earliest promise in the 1990s. We discuss the development of drug-eluting stents and dual antiplatelet strategies and their impact on the perceived benefit of endovascular brachytherapy. For the contemporary era, we propose novel roles for endovascular brachytherapy in complex coronary artery disease and in high-risk patients managed with drug-eluting stents. We discuss the impetus for reducing the requirement and duration of dual antiplatelet therapy using endovascular brachytherapy. We also review innovative opportunities for endovascular brachytherapy after bare-metal stent placement in both coronary and noncoronary territories and offer economic arguments in favor of endovascular brachytherapy. Trials of endovascular brachytherapy in these regimes are merited.

Complete versus incomplete coronary revascularization: definitions, assessment and outcomes

Coronary artery disease is the leading cause of morbidity and mortality worldwide. Selected patients with obstructive coronary artery disease benefit from revascularization with percutaneous coronary intervention (PCI) or coronary artery bypass graft (CABG) surgery. Many (but not all) studies have demonstrated increased survival and greater freedom from adverse cardiovascular events after complete revascularization (CR) than after incomplete revascularization (ICR) in patients with multivessel disease. However, achieving CR after PCI or CABG surgery might not be feasible owing to patient comorbidities, anatomical factors, and technical or procedural considerations. These factors also mean that comparisons between CR and ICR are subject to multiple confounders and are difficult to understand or apply to real-world clinical practice. In this Review, we summarize and critically appraise the evidence linking various types of ICR to adverse outcomes in patients with multivessel disease and stable ischaemic heart disease, non-ST-segment elevation acute coronary syndrome or ST-segment elevation myocardial infarction, with or without cardiogenic shock. In addition, we provide practical recommendations for revascularization in patients with high-risk multivessel disease to optimize their long-term clinical outcomes and identify areas requiring future clinical investigation.

Comparison of Percutaneous Coronary Intervention, Coronary Artery Bypass Grafting and Medical Therapy in Non-ST Elevation Acute Coronary Syndrome Patients With 3-Vessel Disease

BACKGROUND

The aim of this study is to compare the long-term prognosis of non-ST elevation acute coronary syndrome (NSTE-ACS) patients with 3-vessel disease (3VD) who underwent percutaneous coronary intervention (PCI), coronary artery bypass grafting (CABG) or medical therapy (MT).Methods and Results:Overall, 3,928 NSTE-ACS patients with 3VD were consecutively enrolled from April 2004 to February 2011 at Fu Wai Hospital. Patients were followed up for a median of 7.5 years, and were divided into PCI, CABG or MT groups according to their treatment. Compared with patients undergoing PCI, CABG patients had lower rates of myocardial infarction (MI), unplanned revascularization, major adverse cardiovascular and cerebrovascular events (MACCE) and a higher rate of stroke (all P<0.05). Compared with MT, PCI and CABG had lower incidences of all adverse outcomes (all P<0.05), except for a similar rate of stroke between PCI and MT. Kaplan-Meier analysis showed similar results. After adjusting for confounders, CABG was independently associated with a lower risk of cardiac death, revascularization and MACCE compared with PCI (all P<0.05). Compared with MT, PCI reduced long-term risk of death, whereas CABG reduced long-term risk of death, revascularization and MACCE events (all P<0.05).

CONCLUSIONS

In NSTE-ACS patients with 3VD, CABG is independently associated with a lower risk of long-term cardiac death, revascularization and MACCE compared with PCI. Patients who received MT alone had the highest risk of long-term MACCE.

Efficacy and safety of one-month DAPT followed by 23-month ticagrelor monotherapy in patients undergoing proximal LAD stenting: Insights from the GLOBAL LEADERS trial

BACKGROUNDS

Data on optimal antiplatelet therapy in patients undergoing stenting of the proximal left anterior descending artery (LAD) are limited.

METHODS

This is a post-hoc analysis of the GLOBAL LEADERS trial, a prospective, multi-center, randomized controlled trial, comparing the experimental strategy (1-month dual anti-platelet therapy [DAPT] followed by 23-month ticagrelor monotherapy) with the reference regimen (12-month DAPT followed by 12-month aspirin monotherapy) in relation to stenting of the proximal LAD. The primary endpoint was the composite of all-cause death or new Q-wave myocardial infarction (MI) and key secondary safety endpoint was Bleeding Academic Research Consortium (BARC) type 3 or 5 bleeding at two years.

RESULTS

Among 15,845 patients included in the analysis, 3823 (23.9%) patients underwent stenting of the proximal LAD, while 12,022 (75.2%) did not. In the proximal LAD stenting group, there was no significant difference in the risk of the primary endpoint between the two antiplatelet strategies (3.38% vs. 3.93%; hazard ratio [HR]:0.86; 95% CI:0.62-1.20; P_interaction = 0.951). However, the risk of any MI (2.63% vs. 3.88%; HR:0.68; 95% CI:0.47-0.97; P_interaction = 0.015) and any revascularization (7.84% vs. 9.94%; HR:0.78; 95% CI:0.63-0.97; P_interaction = 0.058) was significantly lower in the experimental strategy group, while demonstrating a similar risk of BARC type 3 or 5 bleeding between the two antiplatelet strategies (1.93% vs. 1.99%; HR:0.98; 95% CI:0.62-1.54; P_interaction = 0.981).

CONCLUSIONS

The present study showed patients having stenting to the proximal LAD could potentially benefit from the experimental strategy with lower ischaemic events without a trade-off in major bleeding at two years.

Effectiveness of Clinical, Surgical and Percutaneous Treatment to Prevent Cardiovascular Events in Patients Referred for Elective Coronary Angiography: An Observational Study

Purpose

To ascertain the most appropriate treatment for chronic, stable, coronary artery disease (CAD) in patients submitted to elective coronary angiography.

Patients and Methods

A total of 814 patients included in the prospective cohort study were referred for elective coronary angiography and were followed up on average for 6±1.9 years. Main outcomes were all-cause death, cardiovascular death, non-fatal myocardial infarction (MI) and stroke and late revascularization and their combinations as major adverse cardiac and cerebral events (MACCE): MACCE-1 included cardiovascular death, nonfatal MI, and stroke; MACCE-2 was MACCE-1 plus late revascularization. Survival curves and adjusted Cox proportional hazard models were used to explore the association between the type of treatment and outcomes.

Results

All-cause death was lower in participants submitted to percutaneous coronary intervention (PCI) (0.41, 0.16-1.03, P=0.057) compared to medical treatment (MT). Coronary-artery bypass grafting (CABG) had an overall trend for poorer outcomes: cardiovascular death 2.53 (0.42-15.10), combined cardiovascular death, nonfatal MI, and stroke 2.15 (0.73-6.31) and these events plus late revascularization (2.17, 0.86-5.49). The corresponding numbers for PCI were 0.27 (0.05-1.43) for cardiovascular death, 0.77 (0.32-1.84) for combined cardiovascular death, nonfatal MI, and stroke and 2.35 (1.16-4.77) with the addition of late revascularization. These trends were not influenced by baseline blood pressure, left ventricular ejection fraction and previous MI. Patients with diabetes mellitus had a significantly higher risk of recurrent revascularization when submitted to PCI than CABG.

Conclusion

Patients with confirmed CAD in elective coronary angiography do not have a better prognosis when submitted to CABG comparatively to medical treatment. Patients treated with PCI had a trend for the lower incidence of combined cardiovascular events, at the expense of additional revascularization procedures. Patients without significant CAD had a similar prognosis than CAD patients treated with medical therapy.

Individualizing Revascularization Strategy for Diabetic Patients With Multivessel Coronary Disease

BACKGROUND

In patients with diabetes and multivessel coronary artery disease (CAD), the FREEDOM (Future Revascularization Evaluation in Patients with Diabetes Mellitus: Optimal Management of Multivessel Disease) trial demonstrated that, on average, coronary artery bypass grafting (CABG) was superior to percutaneous coronary intervention (PCI) for major acute cardiovascular events (MACE) and angina reduction. Nonetheless, multivessel PCI remains a common revascularization strategy in the real world.

OBJECTIVES

To translate the results of FREEDOM to individual patients in clinical practice, risk models of the heterogeneity of treatment benefit were built.

METHODS

Using patient-level data from 1,900 FREEDOM patients, the authors developed models to predict 5-year MACE (all-cause mortality, nonfatal myocardial infarction, and nonfatal stroke) and 1-year angina after CABG and PCI using baseline covariates and treatment interactions. Parsimonious models were created to support clinical use. The models were internally validated using bootstrap resampling, and the MACE model was externally validated in a large real-world registry.

RESULTS

The 5-year MACE occurred in 346 (18.2%) patients, and 310 (16.3%) had angina at 1 year. The MACE model included 8 variables and treatment interactions with smoking status (c = 0.67). External validation in stable CAD (c = 0.65) and ACS (c = 0.68) demonstrated comparable performance. The 6-variable angina model included a treatment interaction with SYNTAX score (c = 0.67). PCI was never superior to CABG, and CABG was superior to PCI for MACE in 54.5% of patients and in 100% of patients with history of smoking.

CONCLUSIONS

To help disseminate the results of FREEDOM, the authors created a personalized risk prediction tool for patients with diabetes and multivessel CAD that could be used in shared decision-making for CABG versus PCI by estimating each patient's personal outcomes with both treatments.

Inter-observer variation of Syntax score among cardiac surgeons, clinical and interventional cardiologists

Background:

Despite the complexity of SYNTAX score (SS), guidelines recommend this tool to help choosing between coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI) in patients with left main of three-vessel coronary artery disease. The aim of this study was to compare the inter-observer variation in SS performed by clinical cardiologists (CC), interventional cardiologists (IC), and cardiac surgeons (CS).

Methods:

Seven coronary angiographies from patients with left main and/or three-vessel disease chosen by a heart team were analyzed by 10 CC, 10 IC and 10 CS. SS was calculated via SYNTAX website.

Results:

Kappa concordance was very low between CC and CS (k = 0.176), moderate between CS and IC (k = 0.563), and moderate between CC and IC (0.553). There was a statistically significant difference between CC, who classified more cases as low complexity (70%), and CS, who classified more cases as moderate complexity (80%) (p = 0.041).

Conclusion:

Concordance between SS analyzed by CC, CS and IC is low. The usefulness of SS in decision-making of revascularization strategy is undeniable and evidence supports its use. However, this study highlights the importance of well-trained professionals on calculating the SS. It could avoid misclassification of borderline cases.

Transradial vs. Transfemoral Percutaneous Coronary Intervention in Patients With or Without High Bleeding Risk Criteria

BACKGROUND

The transradial approach is reportedly associated with reduced bleeding complications and mortality after percutaneous coronary intervention (PCI). It is unknown whether the clinical benefits of transradial vs. transfemoral PCI differ between high bleeding risk (HBR) and non-HBR patients.Methods and Results:After excluding patients with acute myocardial infarction, dialysis, and a transbrachial approach from the 13,087 patients undergoing first PCI in the CREDO-Kyoto Registry Cohort-2, 6,828 patients were eligible for this study. Patients were divided into 2 groups according to bleeding risk based on Academic Research Consortium HBR criteria, and then divided into a further 2 groups according to access site, radial or femoral: HBR-radial, n=1,054 (38.3%); HBR-femoral, n=1,699 (61.7%); non-HBR-radial, n=1,682 (41.3%); and non-HBR-femoral, n=2,393 (58.7%). In the HBR group, the 30-day incidence and adjusted risk for major bleeding (1.9% vs. 4.7% [P<0.001]; adjusted hazard ratio [aHR] 0.44, 95% confidence interval [CI] 0.26-0.71 [P<0.001]) and all-cause death (0.3% vs. 0.9% [P=0.04]; aHR 0.30, 95% CI 0.07-0.93 [P=0.04]) were significantly lower in the radial than femoral group. There were no significant differences in the 30-day incidence and adjusted risk for major bleeding (0.5% vs. 1.0% [P=0.09]; aHR 0.68, 95% CI 0.30-1.45 [P=0.33]) or all-cause death (0.1% vs. 0.1% [P=0.96]; aHR 1.51, 95% CI 0.19-9.54 [P=0.67]) between the radial and femoral approaches in the non-HBR group.

CONCLUSIONS

Compared with transfemoral PCI, transradial PCI was associated with lower risk for 30-day major bleeding and mortality in HBR but not non-HBR patients.

Thrombogenic and Inflammatory Reactions to Biomaterials in Medical Devices

Blood-contacting medical devices of different biomaterials are often used to treat various cardiovascular diseases. Thrombus formation is a common cause of failure of cardiovascular devices. Currently, there are no clinically available biomaterials that can totally inhibit thrombosis under the more challenging environments (e.g., low flow in the venous system). Although some biomaterials reduce protein adsorption or cell adhesion, the issue of biomaterial associated with thrombosis and inflammation still exists. To better understand how to develop more thrombosis-resistant medical devices, it is essential to understand the biology and mechano-transduction of thrombus nucleation and progression. In this review, we will compare the mechanisms of thrombus development and progression in the arterial and venous systems. We will address various aspects of thrombosis, starting with biology of thrombosis, mathematical modeling to integrate the mechanism of thrombosis, and thrombus formation on medical devices. Prevention of these problems requires a multifaceted approach that involves more effective and safer thrombolytic agents but more importantly the development of novel thrombosis-resistant biomaterials mimicking the biological characteristics of the endothelium and extracellular matrix tissues that also ameliorate the development and the progression of chronic inflammation as part of the processes associated with the detrimental generation of late thrombosis and neo-atherosclerosis. Until such developments occur, engineers and clinicians must work together to develop devices that require minimal anticoagulants and thrombolytics to mitigate thrombosis and inflammation without causing serious bleeding side effects.

Economic Analysis of Surgical and Interventional Treatments for Patients with Complex Coronary Artery Disease: Insights from a One-Year Single-Center Study

BACKGROUND Surgical treatment methods for patients with complex coronary artery disease (CAD) who have undergone vascular reconstruction mainly include coronary artery bypass graft (CABG) and percutaneous coronary intervention (PCI). The purpose of the study aimed to compare a 1-year follow-up for the patient clinical outcomes and costs between PCI and CABG treatment. MATERIAL AND METHODS There were 840 patients enrolled in this study from July 2015 to September 2016. Among the study participants, 420 patients underwent PCI treatment and 420 patients underwent off-pump CABG. Patients costs were assessed from the perspective of the China healthcare and medical insurance system. EuroQOL 5-dimension 3 levels (EQ-5D-3L) questionnaire was used to evaluate the general health status, and the Seattle Angina Questionnaire (SAQ) was used to assess the disease-specific health status. RESULTS After a 1-year follow-up, the all-cause mortality (P=0.0337), the incidence of major adverse cardiac and cerebrovascular events (P<0.001), and additional revascularization (P<0.001) in PCI group were significantly higher than those in CABG group. Both groups have significant sustained benefits in the SAQ subscale. The CABG group had a higher score on the frequency of angina than the PCI group. In addition, the quality-adjusted life year value of PCI and CABG resulted was 0.8. The average total cost for PCI was $14 643 versus CABG cost of $13 842 (P=0.0492). CONCLUSIONS In the short-term, among the CAD patients with stable triple-vessel or left-main, costs and clinical outcomes are substantially higher for CABG than PCI. Long-term, economic, and health benefits analysis, is warranted.

Effect of Renal Dysfunction on the Risks for Ischemic and Bleeding Events in Patients With Atrial Fibrillation Receiving Percutaneous Coronary Intervention

There is a paucity of studies exploring whether the ischemia-bleeding trade-off could be different according to the stages of renal dysfunction in patients with atrial fibrillation (AF) who underwent percutaneous coronary intervention (PCI). Among 19,598 patients in a pooled database from 3 Japanese PCI studies (CREDO-Kyoto Cohort-2, RESET, and NEXT), 1,547 patients had concomitant AF. Patients were divided into 4 groups according to their renal function (Creatinine clearance [CCr] >60 ml/min: n = 703, 60≥ CCr >30 ml/min: n = 627, CCr ≤30 ml/min: n = 126, Dialysis: n = 91). The cumulative 3-year incidences of both the primary ischemic (ischemic stroke/myocardial infarction) and bleeding (GUSTO moderate/severe) outcome increased incrementally with worsening renal function (11.4%, 12.6%, 16.8%, and 31.7%, p <0.001, and 7.5%, 14.9%, 26.3%, and 29.5%, p <0.001, respectively). Compared with CCr >60 ml/min group, the excess adjusted risk for the primary ischemic outcome was significant only in dialysis group (hazards ratio [HR] 2.15, 95% confidence interval [CI] 1.22 to 3.69, p = 0.009), but not in 60≥ CCr >30 ml/min and CCr ≤30 ml/min groups (HR 0.89, 95% CI 0.62 to 1.29, p = 0.54, and HR 0.94, 95% CI 0.49 to 1.69, p = 0.83, respectively), whereas the excess adjusted risk for the primary bleeding outcome was significant in all 3 groups of renal dysfunction (HR 1.66, 95% CI 1.13 to 2.45, p = 0.01, HR 2.70, 95% CI 1.58 to 4.61, p <0.001, and HR 3.26, 95% CI 1.85 to 5.75, p <0.001, respectively). In conclusion, in AF patients receiving PCI, the worsening renal function was strongly associated with the increasingly higher risk for bleeding events, whereas the excess risk for ischemic events was significant only in patients on dialysis.

Long-term outcomes of percutaneous coronary intervention in grafts and native vessels in coronary artery bypass grafting patients with diabetes mellitus

Background

Atherosclerosis in diabetic patients progresses fast. Evidence on how to choose target vessels of percutaneous coronary interventions (PCIs) in diabetic patients post-coronary artery bypass graft (post-CABG) is insufficient.

Methods

One hundred and fifty-seven patients with diabetes and previous CABG, who underwent PCI of either a graft vessel (GV) (n=44) or a native vessel (NV) (n=113) in the National Center for Cardiovascular Disease, China, were studied. In-hospital and long-term clinical outcomes were compared between the groups.

Results

Diabetic patients with prior CABG had more PCI to native arteries, but the proportion of grafts PCI increased as time went on. Both groups had similar baseline characteristics. Group GV patients compared with group NV had more totally occluded NVs, less totally occluded grafts and more in-stent restenosis. However, there was no difference in in-hospital mortality and long-term incidence of major adverse cardiac event (MACE), cardiac death, nonfatal myocardial infarction (MI), or revascularization. Multivariate logistic regression analysis showed that PCI success [hazard ratio (HR), 11.488; 95% confidence interval (CI), 1.135-116.303; P<0.05] was independent predictor of MACE.

Conclusions

It suggested similar long-term clinical outcomes after PCI in GV or NV in prior CABG patients with diabetes. Thus, the vessel with higher estimated PCI success rate should be prioritized by operators.