1
|
Schindler TH, Sadhu J. Moving towards PET determined coronary flow capacity in outcome prediction after coronary revascularization? Int J Cardiol 2024; 405:131921. [PMID: 38432610 DOI: 10.1016/j.ijcard.2024.131921] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2024] [Accepted: 02/28/2024] [Indexed: 03/05/2024]
Affiliation(s)
- Thomas H Schindler
- Mallinckrodt Institute of Radiology, Division of Nuclear Medicine, Cardiovascular Medicine, Washington University School of Medicine, St. Louis, MO, USA; Cardiovascular Division, John T. Milliken Department of Internal Medicine, Washington University School of Medicine, St. Louis, MO, USA.
| | - Justin Sadhu
- Cardiovascular Division, John T. Milliken Department of Internal Medicine, Washington University School of Medicine, St. Louis, MO, USA
| |
Collapse
|
2
|
Nogueira-Garcia B, Vilela M, Oliveira C, Caldeira D, Martins AM, Nobre Menezes M. A Narrative Review of Revascularization in Chronic Coronary Syndrome/Disease: Concepts and Misconceptions. J Pers Med 2024; 14:506. [PMID: 38793088 PMCID: PMC11122013 DOI: 10.3390/jpm14050506] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2024] [Revised: 05/04/2024] [Accepted: 05/07/2024] [Indexed: 05/26/2024] Open
Abstract
Ischemic heart disease represents a significant global burden of morbidity and mortality. While revascularization strategies are well defined in acute settings, there are uncertainties regarding chronic coronary artery disease treatment. Recent trials have raised doubts about the necessity of revascularization for "stable", chronic coronary syndromes or disease, leading to a shift towards a more conservative approach. However, the issue remains far from settled. In this narrative review, we offer a summary of the most pertinent evidence regarding revascularization for chronic coronary disease, while reflecting on less-often-discussed details of major clinical trials. The cumulative evidence available indicates that there can be a prognostic benefit from revascularization in chronic coronary syndrome patients, provided there is significant ischemia, as demonstrated by either imaging or coronary physiology. Trials that have effectively met this criterion consistently demonstrate a reduction in rates of spontaneous myocardial infarction, which holds both prognostic and clinical significance. The prognostic benefit of revascularization in patients with heart failure with reduced ejection fraction remains especially problematic, with a single contemporary trial favouring surgical revascularization. The very recent publication of a trial focused on revascularizing non-flow-limiting "vulnerable" plaques adds further complexity to the field. The ongoing debates surrounding revascularization in chronic coronary syndromes emphasize the importance of personalized strategies. Revascularization, added to the foundational pillar of medical therapy, should be considered, taking into account symptoms, patient preferences, coronary anatomy and physiology, ischemia tests and intra-coronary imaging.
Collapse
Affiliation(s)
- Beatriz Nogueira-Garcia
- Serviço de Cardiologia, Departamento de Coração e Vasos, CHULN Hospital de Santa Maria, 1649-028 Lisbon, Portugal; (B.N.-G.); (M.V.); (C.O.); (D.C.); (A.M.M.)
- Centro Cardiovascular da Universidade de Lisboa (CCUL@RISE), Faculdade de Medicina, Universidade de Lisboa, 1049-001 Lisbon, Portugal
| | - Marta Vilela
- Serviço de Cardiologia, Departamento de Coração e Vasos, CHULN Hospital de Santa Maria, 1649-028 Lisbon, Portugal; (B.N.-G.); (M.V.); (C.O.); (D.C.); (A.M.M.)
| | - Catarina Oliveira
- Serviço de Cardiologia, Departamento de Coração e Vasos, CHULN Hospital de Santa Maria, 1649-028 Lisbon, Portugal; (B.N.-G.); (M.V.); (C.O.); (D.C.); (A.M.M.)
| | - Daniel Caldeira
- Serviço de Cardiologia, Departamento de Coração e Vasos, CHULN Hospital de Santa Maria, 1649-028 Lisbon, Portugal; (B.N.-G.); (M.V.); (C.O.); (D.C.); (A.M.M.)
- Centro Cardiovascular da Universidade de Lisboa (CCUL@RISE), Faculdade de Medicina, Universidade de Lisboa, 1049-001 Lisbon, Portugal
- Laboratório de Farmacologia Clínica e Terapêutica, Faculdade de Medicina, Universidade de Lisboa, 1049-001 Lisbon, Portugal
- Faculdade de Medicina, Centro de Estudos de Medicina Baseada na Evidência (CEMBE), 1649-028 Lisbon, Portugal
| | - Ana Margarida Martins
- Serviço de Cardiologia, Departamento de Coração e Vasos, CHULN Hospital de Santa Maria, 1649-028 Lisbon, Portugal; (B.N.-G.); (M.V.); (C.O.); (D.C.); (A.M.M.)
| | - Miguel Nobre Menezes
- Serviço de Cardiologia, Departamento de Coração e Vasos, CHULN Hospital de Santa Maria, 1649-028 Lisbon, Portugal; (B.N.-G.); (M.V.); (C.O.); (D.C.); (A.M.M.)
- Centro Cardiovascular da Universidade de Lisboa (CCUL@RISE), Faculdade de Medicina, Universidade de Lisboa, 1049-001 Lisbon, Portugal
| |
Collapse
|
3
|
Ambrosini AP, Fishman ES, Damluji AA, Nanna MG. Chronic Coronary Disease in Older Adults. Med Clin North Am 2024; 108:581-594. [PMID: 38548465 PMCID: PMC11040602 DOI: 10.1016/j.mcna.2023.12.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/02/2024]
Abstract
The number of older adults age ≥75 with chronic coronary disease (CCD) continues to rise. CCD is a major contributor to morbidity, mortality, and disability in older adults. Older adults are underrepresented in randomized controlled trials of CCD, which limits generalizability to older adults living with multiple chronic conditions and geriatric syndromes. This review discusses the presentation of CCD in older adults, reviews the guideline-directed medical and invasive therapies, and recommends a patient-centric approach to making treatment decisions.
Collapse
Affiliation(s)
| | - Emily S Fishman
- Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Abdulla A Damluji
- Inova Center of Outcomes Research, Inova Heart and Vascular Institute, Falls Church, VA, USA; Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Michael G Nanna
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, CT 06520, USA.
| |
Collapse
|
4
|
Hatala R, Hlivák P. Atrial fibrillation in chronic coronary syndromes: a neglected challenge. Eur Heart J 2024; 45:376-378. [PMID: 38104273 DOI: 10.1093/eurheartj/ehad781] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2023] Open
Affiliation(s)
- Robert Hatala
- Department of Cardiology and Angiology, National Institute of Cardiovascular Diseases and the Slovak Medical University School of Medicine, Pod Krásnou hôrkou 1, SK-83348 Bratislava, Slovakia
| | - Peter Hlivák
- Department of Cardiology and Angiology, National Institute of Cardiovascular Diseases and the Slovak Medical University School of Medicine, Pod Krásnou hôrkou 1, SK-83348 Bratislava, Slovakia
| |
Collapse
|
5
|
Jo SH, Kim H, Kim HJ, Lee MH, Seo WW, Kim M, Kim HL. Percutaneous coronary intervention versus medical therapy in stable angina: a matched cohort study. Heart 2024:heartjnl-2023-323541. [PMID: 38286514 DOI: 10.1136/heartjnl-2023-323541] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2023] [Accepted: 12/28/2023] [Indexed: 01/31/2024] Open
Abstract
OBJECTIVE It is uncertain whether percutaneous coronary intervention (PCI) in addition to optimal medical therapy (OMT) can reduce adverse clinical events in the long term as compared with OMT alone in patients with pure stable angina. METHODS We enrolled patients from 2006 to 2010 using the Korean national insurance data. 58 742 patients with pure stable angina with no history of myocardial infarction (MI) nor PCI were candidate, and finally, 5673 patients in the PCI plus OMT group and 5673 in the OMT alone group were selected with 1:1 propensity matching. They were followed up for 9.3 years. RESULTS Primary endpoint, a composite of MI, stroke and cardiac death rate was significantly higher in the PCI group than in the OMT group, 13.5/1000 vs 11.5/1000 person-year with HR of 1.18 (95% CI 1.06 to 1.32, p=0.003). Individual event rate of MI and cardiac death rate was higher in the PCI group than in the OMT group at 9.3 years, 2.9 vs 2.1 (HR 1.38, 95% CI 1.09 to 1.7, p=0.009) and 4.8 vs 3.4/1000 person-year (HR 1.40, 95% CI 1.16 to 1.69, p=0.001), respectively. Revascularisation and total death occurred more in the PCI group as compared with the OMT group, 30.3 vs 8.2 (HR 3.64, 95% CI 3.27 to 4.05, p<0.001) and 13.5 vs 10.6/1000 person-year (HR 1.23, 95% CI 1.12 to 1.40, p<0.001), respectively. In subgroup analysis, the same trend of more event in the PCI group was detected. CONCLUSIONS PCI plus OMT was associated with higher rate of primary endpoint of MI, stroke, cardiac death as compared with OMT alone in patients with pure stable angina at 9.3-year follow-up in large population.
Collapse
Affiliation(s)
- Sang-Ho Jo
- Department of Internal Medicine/ Division of Cardiology, Hallym University Sacred Heart Hospital, Anyang, Korea (the Republic of)
| | - Hoseob Kim
- Department of Data Science, Hanmi Pharmaceuticals Co., Ltd, Seoul, Korea (the Republic of)
| | - Hyun-Jin Kim
- Division of Cardiology, Department of Internal Medicine, Hanyang University College of Medicine, Seoul, Korea (the Republic of)
| | - Min-Ho Lee
- Division of Cardiology, Department of Internal Medicine, Soonchunhyang University Seoul Hospital, Seoul, Korea (the Republic of)
| | - Won-Woo Seo
- Department of Internal Medicine, Department of Internal Medicine, Kangdong Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Korea (the Republic of)
| | - Mina Kim
- Department of Data Science, Hanmi Pharmaceuticals Co., Ltd, Seoul, Korea (the Republic of)
| | - Hack-Lyoung Kim
- Division of Cardiology, Department of Internal Medicine, Seoul Metropolitan Government-Seoul National University Boramae Medical Center, Seoul, Korea (the Republic of)
| |
Collapse
|
6
|
Gould KL, Johnson NP, Roby AE, Bui L, Kitkungvan D, Patel MB, Nguyen T, Kirkeeide R, Haynie M, Arain SA, Charitakis K, Dhoble A, Smalling R, Nascimbene A, Jumean M, Kumar S, Kar B, Sdringola S, Estrera A, Gregoric I, Lai D, Li R, McPherson D, Narula J. Coronary flow capacity and survival prediction after revascularization: physiological basis and clinical implications. Eur Heart J 2024; 45:181-194. [PMID: 37634192 PMCID: PMC10787661 DOI: 10.1093/eurheartj/ehad579] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2023] [Revised: 08/20/2023] [Accepted: 08/21/2023] [Indexed: 08/29/2023] Open
Abstract
BACKGROUND AND AIMS Coronary flow capacity (CFC) is associated with an observed 10-year survival probability for individual patients before and after actual revascularization for comparison to virtual hypothetical ideal complete revascularization. METHODS Stress myocardial perfusion (mL/min/g) and coronary flow reserve (CFR) per pixel were quantified in 6979 coronary artery disease (CAD) subjects using Rb-82 positron emission tomography (PET) for CFC maps of artery-specific size-severity abnormalities expressed as percent left ventricle with prospective follow-up to define survival probability per-decade as fraction of 1.0. RESULTS Severely reduced CFC in 6979 subjects predicted low survival probability that improved by 42% after revascularization compared with no revascularization for comparable severity (P = .0015). For 283 pre-and-post-procedure PET pairs, severely reduced regional CFC-associated survival probability improved heterogeneously after revascularization (P < .001), more so after bypass surgery than percutaneous coronary interventions (P < .001) but normalized in only 5.7%; non-severe baseline CFC or survival probability did not improve compared with severe CFC (P = .00001). Observed CFC-associated survival probability after actual revascularization was lower than virtual ideal hypothetical complete post-revascularization survival probability due to residual CAD or failed revascularization (P < .001) unrelated to gender or microvascular dysfunction. Severely reduced CFC in 2552 post-revascularization subjects associated with low survival probability also improved after repeat revascularization compared with no repeat procedures (P = .025). CONCLUSIONS Severely reduced CFC and associated observed survival probability improved after first and repeat revascularization compared with no revascularization for comparable CFC severity. Non-severe CFC showed no benefit. Discordance between observed actual and virtual hypothetical post-revascularization survival probability revealed residual CAD or failed revascularization.
Collapse
Affiliation(s)
- K Lance Gould
- Department of Medicine, Division of Cardiology, Weatherhead P.E.T. Center, McGovern Medical School, University of Texas Health Science Center, and Memorial Hermann Hospital, 6431 Fannin St., Room MSB 4.256, Houston, TX 77030, USA
- Department of Medicine, Division of Cardiology, McGovern Medical School, University of Texas Health Science Center, and Memorial Hermann Hospital, 6431 Fannin St, Rm 4.256 MSB, Houston, TX 77005, USA
| | - Nils P Johnson
- Department of Medicine, Division of Cardiology, Weatherhead P.E.T. Center, McGovern Medical School, University of Texas Health Science Center, and Memorial Hermann Hospital, 6431 Fannin St., Room MSB 4.256, Houston, TX 77030, USA
- Department of Medicine, Division of Cardiology, McGovern Medical School, University of Texas Health Science Center, and Memorial Hermann Hospital, 6431 Fannin St, Rm 4.256 MSB, Houston, TX 77005, USA
| | - Amanda E Roby
- Department of Medicine, Division of Cardiology, Weatherhead P.E.T. Center, McGovern Medical School, University of Texas Health Science Center, and Memorial Hermann Hospital, 6431 Fannin St., Room MSB 4.256, Houston, TX 77030, USA
- Department of Medicine, Division of Cardiology, McGovern Medical School, University of Texas Health Science Center, and Memorial Hermann Hospital, 6431 Fannin St, Rm 4.256 MSB, Houston, TX 77005, USA
| | - Linh Bui
- Department of Medicine, Division of Cardiology, Weatherhead P.E.T. Center, McGovern Medical School, University of Texas Health Science Center, and Memorial Hermann Hospital, 6431 Fannin St., Room MSB 4.256, Houston, TX 77030, USA
- Department of Medicine, Division of Cardiology, McGovern Medical School, University of Texas Health Science Center, and Memorial Hermann Hospital, 6431 Fannin St, Rm 4.256 MSB, Houston, TX 77005, USA
| | - Danai Kitkungvan
- Department of Medicine, Division of Cardiology, Weatherhead P.E.T. Center, McGovern Medical School, University of Texas Health Science Center, and Memorial Hermann Hospital, 6431 Fannin St., Room MSB 4.256, Houston, TX 77030, USA
- Department of Medicine, Division of Cardiology, McGovern Medical School, University of Texas Health Science Center, and Memorial Hermann Hospital, 6431 Fannin St, Rm 4.256 MSB, Houston, TX 77005, USA
| | - Monica B Patel
- Department of Medicine, Division of Cardiology, Weatherhead P.E.T. Center, McGovern Medical School, University of Texas Health Science Center, and Memorial Hermann Hospital, 6431 Fannin St., Room MSB 4.256, Houston, TX 77030, USA
- Department of Medicine, Division of Cardiology, McGovern Medical School, University of Texas Health Science Center, and Memorial Hermann Hospital, 6431 Fannin St, Rm 4.256 MSB, Houston, TX 77005, USA
| | - Tung Nguyen
- Department of Medicine, Division of Cardiology, Weatherhead P.E.T. Center, McGovern Medical School, University of Texas Health Science Center, and Memorial Hermann Hospital, 6431 Fannin St., Room MSB 4.256, Houston, TX 77030, USA
- Department of Medicine, Division of Cardiology, McGovern Medical School, University of Texas Health Science Center, and Memorial Hermann Hospital, 6431 Fannin St, Rm 4.256 MSB, Houston, TX 77005, USA
| | - Richard Kirkeeide
- Department of Medicine, Division of Cardiology, Weatherhead P.E.T. Center, McGovern Medical School, University of Texas Health Science Center, and Memorial Hermann Hospital, 6431 Fannin St., Room MSB 4.256, Houston, TX 77030, USA
- Department of Medicine, Division of Cardiology, McGovern Medical School, University of Texas Health Science Center, and Memorial Hermann Hospital, 6431 Fannin St, Rm 4.256 MSB, Houston, TX 77005, USA
| | - Mary Haynie
- Department of Medicine, Division of Cardiology, Weatherhead P.E.T. Center, McGovern Medical School, University of Texas Health Science Center, and Memorial Hermann Hospital, 6431 Fannin St., Room MSB 4.256, Houston, TX 77030, USA
- Department of Medicine, Division of Cardiology, McGovern Medical School, University of Texas Health Science Center, and Memorial Hermann Hospital, 6431 Fannin St, Rm 4.256 MSB, Houston, TX 77005, USA
| | - Salman A Arain
- Department of Medicine, Division of Cardiology, McGovern Medical School, University of Texas Health Science Center, and Memorial Hermann Hospital, 6431 Fannin St, Rm 4.256 MSB, Houston, TX 77005, USA
| | - Konstantinos Charitakis
- Department of Medicine, Division of Cardiology, McGovern Medical School, University of Texas Health Science Center, and Memorial Hermann Hospital, 6431 Fannin St, Rm 4.256 MSB, Houston, TX 77005, USA
| | - Abhijeet Dhoble
- Department of Medicine, Division of Cardiology, McGovern Medical School, University of Texas Health Science Center, and Memorial Hermann Hospital, 6431 Fannin St, Rm 4.256 MSB, Houston, TX 77005, USA
| | - Richard Smalling
- Department of Medicine, Division of Cardiology, McGovern Medical School, University of Texas Health Science Center, and Memorial Hermann Hospital, 6431 Fannin St, Rm 4.256 MSB, Houston, TX 77005, USA
| | - Angelo Nascimbene
- Department of Advanced Cardiopulmonary Therapies and Transplantation, McGovern Medical School, University of Texas Health Science Center, and Memorial Hermann Hospital, Houston, TX, USA
| | - Marwan Jumean
- Department of Advanced Cardiopulmonary Therapies and Transplantation, McGovern Medical School, University of Texas Health Science Center, and Memorial Hermann Hospital, Houston, TX, USA
| | - Sachin Kumar
- Department of Advanced Cardiopulmonary Therapies and Transplantation, McGovern Medical School, University of Texas Health Science Center, and Memorial Hermann Hospital, Houston, TX, USA
| | - Biswajit Kar
- Department of Advanced Cardiopulmonary Therapies and Transplantation, McGovern Medical School, University of Texas Health Science Center, and Memorial Hermann Hospital, Houston, TX, USA
| | - Stefano Sdringola
- Department of Medicine, Division of Cardiology, McGovern Medical School, University of Texas Health Science Center, and Memorial Hermann Hospital, 6431 Fannin St, Rm 4.256 MSB, Houston, TX 77005, USA
| | - Anthony Estrera
- Department of Cardiothoracic Vascular Surgery, McGovern Medical School, University of Texas Health Science Center, Memorial Hermann Hospital, Houston, TX, USA
| | - Igor Gregoric
- Department of Advanced Cardiopulmonary Therapies and Transplantation, McGovern Medical School, University of Texas Health Science Center, and Memorial Hermann Hospital, Houston, TX, USA
| | - Dejian Lai
- Department of Biostatistics and Data Science, University of Texas School of Public Health-Houston, Houston, TX, USA
| | - Ruosha Li
- Department of Biostatistics and Data Science, University of Texas School of Public Health-Houston, Houston, TX, USA
| | - David McPherson
- Department of Medicine, Division of Cardiology, McGovern Medical School, University of Texas Health Science Center, and Memorial Hermann Hospital, 6431 Fannin St, Rm 4.256 MSB, Houston, TX 77005, USA
| | - Jagat Narula
- Department of Medicine, Division of Cardiology, Weatherhead P.E.T. Center, McGovern Medical School, University of Texas Health Science Center, and Memorial Hermann Hospital, 6431 Fannin St., Room MSB 4.256, Houston, TX 77030, USA
- Department of Medicine, Division of Cardiology, McGovern Medical School, University of Texas Health Science Center, and Memorial Hermann Hospital, 6431 Fannin St, Rm 4.256 MSB, Houston, TX 77005, USA
| |
Collapse
|
7
|
Seleznova Y, Bruder O, Loeser S, Artmann J, Shukri A, Naumann M, Stock S, Wein B, Müller D. Health economic consequences of optimal vs. observed guideline adherence of coronary angiography in patients with suspected obstructive stable coronary artery in Germany: a microsimulation model. EUROPEAN HEART JOURNAL. QUALITY OF CARE & CLINICAL OUTCOMES 2024; 10:45-54. [PMID: 36893809 PMCID: PMC10785585 DOI: 10.1093/ehjqcco/qcad015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/14/2023] [Revised: 02/10/2023] [Accepted: 03/07/2023] [Indexed: 03/11/2023]
Abstract
AIMS While the number of patients with stable coronary artery disease (SCAD) is similar across European countries, Germany has the highest per capita volume of coronary angiographies (CA). This study evaluated the health economic consequences of guideline-non-adherent use of CA in patients with SCAD. METHODS AND RESULTS As part of the ENLIGHT-KHK trial, a prospective observational study, this microsimulation model compared the number of major adverse cardiac events (MACE) and the costs of real-world use of CA with those of (assumed) complete guideline-adherent use (according to the German National Disease Management Guideline 2019). The model considered non-invasive testing, CA, revascularization, MACE (30 days after CA), and medical costs. Model inputs were obtained from the ENLIGHT-KHK trial (i.e. patients' records, a patient questionnaire, and claims data). Incremental cost-effectiveness ratios were calculated by comparing the differences in costs and MACE avoided from the perspective of the Statutory Health Insurance (SHI). Independent on pre-test probability (PTP) of SCAD, complete guideline adherence for usage of CA would result in a slightly lower rate of MACE (-0.0017) and less cost (€-807) per person compared with real-world guideline adherence. While cost savings were shown for moderate and low PTP (€901 and €502, respectively), for a high PTP, a guideline-adherent process results in slightly higher costs (€78) compared with real-world guideline adherence. Sensitivity analyses confirmed the results. CONCLUSION Our analysis indicates that improving guideline adherence in clinical practice by reducing the amount of CAs in patients with SCAD would lead to cost savings for the German SHI.
Collapse
Affiliation(s)
- Yana Seleznova
- Institute for Health Economics and Clinical Epidemiology, Faculty of Medicine and University Hospital Cologne, University of Cologne, Gleueler Straße 176-178, 50935 Cologne, Germany
| | - Oliver Bruder
- Department of Cardiology and Angiology, Contilia Heart and Vascular Center, Elisabeth-Krankenhaus Essen, Klara-Kopp-Weg 1, 45138 Essen, Germany
- Faculty of Medicine, Ruhr University Bochum, 44801, Bochum, Germany
| | - Simon Loeser
- AOK Rheinland/Hamburg, Kasernenstraße 61, 40213 Düsseldorf, Germany
| | - Jörg Artmann
- AOK Rheinland/Hamburg, Kasernenstraße 61, 40213 Düsseldorf, Germany
| | - Arim Shukri
- Institute for Health Economics and Clinical Epidemiology, Faculty of Medicine and University Hospital Cologne, University of Cologne, Gleueler Straße 176-178, 50935 Cologne, Germany
| | - Marie Naumann
- Institute for Health Economics and Clinical Epidemiology, Faculty of Medicine and University Hospital Cologne, University of Cologne, Gleueler Straße 176-178, 50935 Cologne, Germany
| | - Stephanie Stock
- Institute for Health Economics and Clinical Epidemiology, Faculty of Medicine and University Hospital Cologne, University of Cologne, Gleueler Straße 176-178, 50935 Cologne, Germany
| | - Bastian Wein
- Department of Cardiology and Angiology, Contilia Heart and Vascular Center, Elisabeth-Krankenhaus Essen, Klara-Kopp-Weg 1, 45138 Essen, Germany
- Department of Cardiology, Faculty of Medicine, University of Augsburg, Stenglinstrasse 2, 86156, Augsburg, Germany
| | - Dirk Müller
- Institute for Health Economics and Clinical Epidemiology, Faculty of Medicine and University Hospital Cologne, University of Cologne, Gleueler Straße 176-178, 50935 Cologne, Germany
| |
Collapse
|
8
|
Chen Y, Zhong J, Chen L, Hong R, Yan Y, Chen L, Chen Q, Luo Y. Effects of percutaneous coronary intervention and diabetes mellitus on short- and long-term prognosis assessed by the three-vessel quantitative flow ratio. Diabetes Res Clin Pract 2023; 206:111013. [PMID: 37972858 DOI: 10.1016/j.diabres.2023.111013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2023] [Revised: 10/30/2023] [Accepted: 11/13/2023] [Indexed: 11/19/2023]
Abstract
AIMS We aimed to investigate the impact of percutaneous coronary intervention (PCI) and diabetes mellitus (DM) on short- and long-term prognosis in patients with coronary artery disease using three-vessel quantitative flow ratio (3 V-QFR) assessment. METHODS A retrospective analysis of 2440 vessels in 1181 patients who underwent PCI was performed. The patients were categorized according to the presence or absence of DM and the median 3 V-QFR. The primary outcome was the occurrence of major adverse cardiac events (MACE), defined as a combination of cardiovascular death, myocardial infarction, and ischemia-driven revascularization, over a 5-year period. RESULTS The pre-PCI and post-PCI 3 V-QFR values for the entire population were 2.37 (2.04-2.56) and 2.94 (2.82-3.00), respectively. Landmark analysis showed that the incidence of MACE was comparable among all groups within the first year (log-rank p = 0.088). Over the course of 2 years, the incidence of MACE was higher in both groups with a post-PCI 3 V-QFR < 2.94 (log-rank p < 0.001). However, from 2 to 5 years, patients with DM had higher rates of MACE (log-rank p = 0.013). CONCLUSIONS In the short term, a low post-PCI 3 V-QFR is a predictor of high risk for MACE. However, in the long term, DM emerges as the dominant risk factor.
Collapse
Affiliation(s)
- Yuxiang Chen
- Department of Cardiology, Fujian Medical University Union Hospital, No. 29 Xin Quan Road, Fuzhou, Fujian 350001, PR China; Fujian Institute of Coronary Heart Disease, Fuzhou, Fujian 350001, PR China; Fujian Heart Medical Center, Fuzhou, Fujian 350001, PR China.
| | - Jiaxin Zhong
- Department of Cardiology, Fujian Medical University Union Hospital, No. 29 Xin Quan Road, Fuzhou, Fujian 350001, PR China; Fujian Institute of Coronary Heart Disease, Fuzhou, Fujian 350001, PR China; Fujian Heart Medical Center, Fuzhou, Fujian 350001, PR China.
| | - Lihua Chen
- Department of Cardiology, Fujian Medical University Union Hospital, No. 29 Xin Quan Road, Fuzhou, Fujian 350001, PR China; Fujian Institute of Coronary Heart Disease, Fuzhou, Fujian 350001, PR China; Fujian Heart Medical Center, Fuzhou, Fujian 350001, PR China.
| | - Ruijin Hong
- Department of Cardiology, Fujian Medical University Union Hospital, No. 29 Xin Quan Road, Fuzhou, Fujian 350001, PR China; Fujian Institute of Coronary Heart Disease, Fuzhou, Fujian 350001, PR China; Fujian Heart Medical Center, Fuzhou, Fujian 350001, PR China.
| | - Yuanming Yan
- Department of Cardiology, Fujian Medical University Union Hospital, No. 29 Xin Quan Road, Fuzhou, Fujian 350001, PR China; Fujian Institute of Coronary Heart Disease, Fuzhou, Fujian 350001, PR China; Fujian Heart Medical Center, Fuzhou, Fujian 350001, PR China.
| | - Lianglong Chen
- Department of Cardiology, Fujian Medical University Union Hospital, No. 29 Xin Quan Road, Fuzhou, Fujian 350001, PR China; Fujian Institute of Coronary Heart Disease, Fuzhou, Fujian 350001, PR China; Fujian Heart Medical Center, Fuzhou, Fujian 350001, PR China.
| | - Qin Chen
- Department of Cardiology, Fujian Medical University Union Hospital, No. 29 Xin Quan Road, Fuzhou, Fujian 350001, PR China; Fujian Institute of Coronary Heart Disease, Fuzhou, Fujian 350001, PR China; Fujian Heart Medical Center, Fuzhou, Fujian 350001, PR China.
| | - Yukun Luo
- Department of Cardiology, Fujian Medical University Union Hospital, No. 29 Xin Quan Road, Fuzhou, Fujian 350001, PR China; Fujian Institute of Coronary Heart Disease, Fuzhou, Fujian 350001, PR China; Fujian Heart Medical Center, Fuzhou, Fujian 350001, PR China.
| |
Collapse
|
9
|
Gomes WJ, Marin-Cuartas M, Bakaeen F, Sádaba JR, Dayan V, Almeida R, Parolari A, Myers PO, Borger MA. The ISCHEMIA trial revisited: setting the record straight on the benefits of coronary bypass surgery and the misinterpretation of a landmark trial. Eur J Cardiothorac Surg 2023; 64:ezad361. [PMID: 37889258 DOI: 10.1093/ejcts/ezad361] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2023] [Revised: 10/12/2023] [Accepted: 10/26/2023] [Indexed: 10/28/2023] Open
Abstract
OBJECTIVES The ISCHEMIA trial is a landmark study that has been the subject of heated debate within the cardiovascular community. In this analysis of the ISCHEMIA trial, we aim to set the record straight on the benefits of coronary artery bypass grafting (CABG) and the misinterpretation of this landmark trial. We sought to clarify and reorient this misinterpretation. METHODS We herein analyse the ISCHEMIA trial in detail and describe how its misinterpretation has led to an erroneous guideline recommendation downgrading for prognosis-altering surgical therapy in these at-risk patients. RESULTS The interim ISCHEMIA trial findings align with previous evidence where CABG reduces the long-term risks of myocardial infarction and mortality in advanced coronary artery disease. The trial outcomes of a significantly lower rate of cardiovascular mortality and a higher rate of non-cardiovascular mortality with the invasive strategy are explained according to landmark evidence. CONCLUSIONS The ISCHEMIA trial findings are aligned with previous evidence and should not be used to downgrade recommendations in recent guidelines for the indisputable benefits of CABG.
Collapse
Affiliation(s)
- Walter J Gomes
- Cardiovascular Surgery Discipline, Escola Paulista de Medicina and São Paulo Hospital, Federal University of São Paulo, São Paulo, Brazil
| | - Mateo Marin-Cuartas
- University Department of Cardiac Surgery, Leipzig Heart Center, Leipzig, Germany
| | - Faisal Bakaeen
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH, USA
| | - J Rafael Sádaba
- Department of Cardiac Surgery, University Hospital of Navarra, Pamplona, Spain
| | - Victor Dayan
- Centro Cardiovascular Universitario, Montevideo, Uruguay
| | - Rui Almeida
- University Center Assis Gurgacz Foundation, Cascavel, Paraná, Brazil
| | - Alessandro Parolari
- Unit of Cardiac Surgery, IRCCS Policlinico S. Donato, University of Milan, S. Donato Milanese, Italy
| | - Patrick O Myers
- Division of Cardiac Surgery, CHUV-Lausanne University Hospital, Lausanne, Switzerland
| | - Michael A Borger
- University Department of Cardiac Surgery, Leipzig Heart Center, Leipzig, Germany
| |
Collapse
|
10
|
Derdeyn CP, Wall M. Counterpoint: stenting for idiopathic intracranial hypertension should be trialed. J Neurointerv Surg 2023; 15:1063-1064. [PMID: 37344173 DOI: 10.1136/jnis-2023-020404] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/11/2023] [Indexed: 06/23/2023]
Affiliation(s)
- Colin P Derdeyn
- Radiology, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| | - Michael Wall
- Ophthalmology, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| |
Collapse
|
11
|
Salihu A, Roguelov C, Fournier S, Coucke P, Eeckhout E. Intracoronary Brachytherapy for Restenosis: 20 Years of Follow-Up. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2023; 54:1-4. [PMID: 37087307 DOI: 10.1016/j.carrev.2023.04.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2023] [Revised: 04/06/2023] [Accepted: 04/10/2023] [Indexed: 04/24/2023]
Abstract
BACKGROUND/PURPOSE Intracoronary brachytherapy (ICB) has mainly been used to treat in-stent restenosis following percutaneous coronary intervention and was virtually abandoned about 20 years ago. However, patients treated with this strategy are still alive and some teams continue to perform this therapy. We aimed to investigate the very long-term clinical outcome of patients treated with ICB. METHODS/MATERIALS A total of 173 consecutive patients who had been treated with ICB at a large tertiary referral centre between 1998 and 2003 were included. The primary endpoint of the study was all-cause mortality. The secondary endpoints were as follows: occurrence of major adverse cardiac events (MACE, defined as all-cause death, non-fatal myocardial infarction, or target vessel revascularization), cardiac death, and presence of angina at the end of follow-up. RESULTS Patients' mean age at the time of ICB was 64 ± 10 years and 77 % were male. Restenosis (bare metal stent vs. balloon angioplasty) was the only indication for ICB. Unstable angina was present in 34 % of the patients. Follow-up was available for 166 patients. After a mean follow-up of 20 ± 1.3 years, 66 % of the patients had died (including 74 patients (67 %) with cardiac death). Cumulative MACE rate at 20 years was 96 %. CONCLUSIONS Very long-term follow-up of patients with in-stent restenosis treated with ICB confirmed a high all-cause mortality rate mainly due to cardiac causes and MACEs.
Collapse
Affiliation(s)
- Adil Salihu
- Department of Cardiology, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland.
| | - Christan Roguelov
- Department of Cardiology, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
| | - Stephane Fournier
- Department of Cardiology, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
| | | | - Eric Eeckhout
- Department of Cardiology, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
| |
Collapse
|
12
|
Terentes-Printzios D, Gkini KP, Oikonomou D, Gardikioti V, Aznaouridis K, Dima I, Tsioufis K, Vlachopoulos C. Prognostic Value of Post-PCI Angiography-Derived Fractional Flow Reserve: A Systematic Review and Meta-Analysis of Cohort Studies. J Pers Med 2023; 13:1251. [PMID: 37623501 PMCID: PMC10455379 DOI: 10.3390/jpm13081251] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2023] [Revised: 08/07/2023] [Accepted: 08/09/2023] [Indexed: 08/26/2023] Open
Abstract
The post-percutaneous coronary intervention (post-PCI) fractional flow reserve (FFR) can detect suboptimal PCI or residual ischemia and potentially lead to fewer adverse clinical outcomes. We sought to investigate the predictive value of the angiography-derived FFR for adverse cardiovascular events in patients after PCI. We conducted a comprehensive search of electronic databases, MEDLINE, EMBASE, and the Cochrane Library, for studies published until March 2023 that investigated the prognostic role of angiography-derived fractional flow reserve values after PCI. We investigated the best predictive ability of the post-PCI angiography-derived FFR and relative risk (RR) estimates with 95% confidence intervals (CIs) between post-PCI angiography-derived FFR values and adverse events. Thirteen cohort studies involving 6961 patients (9719 vascular lesions; mean follow-up: 2.2 years) were included in this meta-analysis. The pooled HR of the studies using specific cut-off points for post-PCI angiography-derived FFR was 4.13 (95% CI, 2.92-5.82) for total cardiovascular events, while the pooled HRs for target vessel revascularization, cardiac death, target vessel myocardial infarction, and target lesion revascularization were 6.87 (95% CI, 4.93-9.56), 6.17 (95% CI, 3.52-10.80), 3.98 (95% CI, 2.37-6.66) and 6.27 (95% CI, 3.08-12.79), respectively. In a sensitivity analysis of three studies with 1789 patients assessing the predictive role of the post-PCI angiography-derived FFR as a continuous variable, we found a 58% risk reduction for future adverse events per 0.1 increase in the post-PCI angiography-derived FFR value. In conclusion, post-PCI angiography-derived FFR is an effective tool for predicting adverse cardiovascular events and could be potentially used in decision making, both during PCI and in the long-term follow-up.
Collapse
|
13
|
Chen H, Hong L, Xi G, Wang H, Hu J, Liu Q, Yang L. Prognostic value of quantitative flow ratio in patients with coronary heart disease after percutaneous coronary intervention therapy: a meta-analysis. Front Cardiovasc Med 2023; 10:1164290. [PMID: 37608814 PMCID: PMC10441770 DOI: 10.3389/fcvm.2023.1164290] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2023] [Accepted: 07/24/2023] [Indexed: 08/24/2023] Open
Abstract
Background Coronary atherosclerotic heart disease is one of the most serious health and life-threatening diseases. There is no doubt that despite the increasing number of assessment methods used clinically, the prognosis assessment is still not ideal, and newer assessment methods are needed. Objective To investigate the predictive value of quantitative flow ratio (QFR) for adverse events (vessel-oriented composite endpoint events/target lesion failure) in patients after percutaneous coronary intervention (PCI). Method Eight studies involving 4,173 patients (5,688 vascular lesions) were included. These are studies on the relationship between QFR values and prognosis of adverse cardiac events after PCI. This meta-analysis was performed after quality assessment and data extraction of clinical trials data that met the inclusion criteria. Result Each of the eight studies described the cut-off values for the best predictive ability of post-PCI QFR and the hazard ratio (HR) between QFR values and adverse events, respectively. The pooled HR of these studies was 4.72 (95% CI: 3.29-6.75). Concurrently, lower post-PCI QFR values were associated with the occurrence of individual clinical events (cardiac death/myocardial infarction/target vessel revascularization), with relative risk values of 6.51 (95% CI: 4.96-8.53), 4.83 (95% CI: 3.08-7.57), and 4.21 (95% CI: 2.66-6.68), respectively. Conclusion QFR may have great potential in the assessment of prognosis. It is necessary to measure QFR value after PCI. A lower QFR value after PCI was an important predictor for experiencing adverse events.
Collapse
Affiliation(s)
- Huaigang Chen
- Medical College of Nanchang University, Nanchang, China
- Department of Cardiology, Jiangxi Provincial People’s Hospital, The First Affiliated Hospital of Nanchang Medical College, Nanchang, China
| | - Lang Hong
- Department of Cardiology, Jiangxi Provincial People’s Hospital, The First Affiliated Hospital of Nanchang Medical College, Nanchang, China
| | - Gang Xi
- Department of Cardiology, The Third People's Hospital of Jingdezhen, Jingdezhen, China
| | - Hong Wang
- Department of Cardiology, Jiangxi Provincial People’s Hospital, The First Affiliated Hospital of Nanchang Medical College, Nanchang, China
| | - Jing Hu
- Department of Cardiology, Jiangxi Provincial People’s Hospital, The First Affiliated Hospital of Nanchang Medical College, Nanchang, China
| | - Qi Liu
- Medical College of Nanchang University, Nanchang, China
- Department of Cardiology, Jiangxi Provincial People’s Hospital, The First Affiliated Hospital of Nanchang Medical College, Nanchang, China
| | - Liu Yang
- Department of Cardiology, Jiangxi Provincial People’s Hospital, The First Affiliated Hospital of Nanchang Medical College, Nanchang, China
| |
Collapse
|
14
|
Goel H, Carey M, Elshaikh A, Krinock M, Goyal D, Nadar SK. Cardioprotective and Antianginal Efficacy of Nicorandil: A Comprehensive Review. J Cardiovasc Pharmacol 2023; 82:69-85. [PMID: 37256547 DOI: 10.1097/fjc.0000000000001436] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2022] [Accepted: 04/15/2023] [Indexed: 06/01/2023]
Abstract
ABSTRACT Angina pectoris remains a significant burden despite advances in medical therapy and coronary revascularization. Many patients (up to 30%) with angina have normal coronary arteries, with coronary microvascular disease and/or coronary artery vasospasm being major drivers of the myocardial demand-supply mismatch. Even among patients revascularized for symptomatic epicardial coronary stenosis, recurrent angina remains highly prevalent. Medical therapy for angina currently centers around 2 disparate goals, viz secondary prevention of hard clinical outcomes and symptom control. Vasodilators, such as nitrates, have been first-line antianginal agents for decades, along with beta-blockers and calcium channel blockers. However, efficacy in symptoms control is heterogenous, depending on underlying mechanism(s) of angina in an individual patient, often necessitating multiple agents. Nicorandil (NCO) is an antianginal agent first discovered in the late 1970s with a uniquely dual mechanism of action. Like a typical nitrate, it mediates medium-large vessel vasodilation through nitric oxide. In addition, NCO has adenosine triphosphate (ATP)-dependent potassium channel agonist activity (K ATP ), mediating microvascular dilatation. Hence, it has proven effective in both coronary artery vasospasm and coronary microvascular disease, typically challenging patient populations. Moreover, emerging evidence suggests that cardiomyocyte protection against ischemia through ischemic preconditioning may be mediated through K ATP agonism. Finally, there is now fairly firm evidence in favor of NCO in terms of hard event reduction among patients with stable coronary artery disease, following myocardial infarction, and perhaps even among patients with congestive heart failure. This review aims to summarize the mechanism of action of NCO, its efficacy as an antianginal, and current evidence behind its impact on hard outcomes. Finally, we review other cardiac and emerging noncardiac indications for NCO use.
Collapse
Affiliation(s)
- Harsh Goel
- Department of Medicine, St Luke's University Hospital, Bethlehem, PA
- Lewis Katz School of Medicine, Temple University, Philadelphia, PA
| | - Matthew Carey
- Department of Medicine, St Luke's University Hospital, Bethlehem, PA
| | | | - Matthew Krinock
- Department of Medicine, St Luke's University Hospital, Bethlehem, PA
- ‡Department of Cardiology, St Luke's University Hospital, Bethlehem, PA
| | - Deepak Goyal
- Department of Cardiology, Worcestershire Acute Hospitals NHS Trust, Worcester, UK; and
| | - Sunil K Nadar
- Department of Cardiology, Dudley Group of Hospitals NHS Trust, Dudley, UK
| |
Collapse
|
15
|
Fremes SE, Marquis-Gravel G, Gaudino MFL, Jolicoeur EM, Bédard S, Masterson Creber R, Ruel M, Vervoort D, Wijeysundera HC, Farkouh ME, Rouleau JL. STICH3C: Rationale and Study Protocol. Circ Cardiovasc Interv 2023; 16:e012527. [PMID: 37582169 DOI: 10.1161/circinterventions.122.012527] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2022] [Accepted: 07/03/2023] [Indexed: 08/17/2023]
Abstract
BACKGROUND Coronary artery bypass grafting (CABG) is the recommended mode of revascularization in patients with ischemic left ventricular dysfunction (iLVSD) and multivessel disease. However, contemporary percutaneous coronary intervention (PCI) outcomes have improved with the integration of novel technologies and refinement of revascularization strategies, and PCI is often used in clinical practice in this population. There is a lack of evidence from randomized trials comparing contemporary state-of-the-art PCI versus CABG for the treatment of iLVSD and multivessel disease. This was the impetus for the STICH3C trial (Canadian CABG or PCI in Patients With Ischemic Cardiomyopathy), described here. METHODS The STICH3C trial is a prospective, unblinded, international, multicenter trial with an expected sample size of 754 participants from ≈45 centers. Patients with multivessel/left main coronary artery disease and iLVSD with left ventricular ejection fraction ≤40% considered by the local Heart Team appropriate for and amenable to revascularization by both modes of revascularization will be randomized in a 1:1 ratio to state-of-the-art PCI or CABG. RESULTS The primary end point is the composite of death from any cause, stroke, spontaneous myocardial infarction, urgent repeat revascularization, or heart failure readmission, summarized as a time-to-event outcome. The key hierarchical end point is time to death and frequency of hospitalizations for heart failure. The key safety outcome is a composite of major adverse events. Disease-specific quality-of-life and health economics measures will be compared between groups. Participants will be followed for a median of 5 years, with a minimum follow-up of 4 years. CONCLUSIONS STICH3C will directly inform patients, clinicians, and international practice guidelines about the efficacy and safety of CABG versus PCI in patients with iLVSD. The results will provide novel and broad evidence, including clinical events, health status, and economic assessments, to guide care for patients with iLVSD and severe coronary artery disease. REGISTRATION URL: https://clinicaltrials.gov/; Unique identifier: NCT05427370.
Collapse
Affiliation(s)
- Stephen E Fremes
- Schulich Heart Centre, Sunnybrook Health Sciences Centre, University of Toronto, Ontario, Canada (S.E.F., D.V., H.C.W.)
| | | | - Mario F L Gaudino
- Department of Cardiothoracic Surgery (M.F.L.G.), Weill Cornell Medicine, New York City, NY
| | - E Marc Jolicoeur
- Department of Cardiothoracic Surgery (M.F.L.G.), Weill Cornell Medicine, New York City, NY
| | - Sylvain Bédard
- Centre d'excellence sur le partenariat avec les patients et le public, Montreal, Quebec, Canada (S.B.)
| | | | - Marc Ruel
- Division of Cardiac Surgery, University of Ottawa Heart Institute, Ontario, Canada (M.R.)
| | - Dominique Vervoort
- Schulich Heart Centre, Sunnybrook Health Sciences Centre, University of Toronto, Ontario, Canada (S.E.F., D.V., H.C.W.)
| | - Harindra C Wijeysundera
- Schulich Heart Centre, Sunnybrook Health Sciences Centre, University of Toronto, Ontario, Canada (S.E.F., D.V., H.C.W.)
| | - Michael E Farkouh
- Division of Cardiology, Peter Munk Cardiac Centre, Toronto General Hospital, Ontario, Canada (M.E.F.)
| | - Jean-Lucien Rouleau
- Montreal Heart Institute, University of Montreal, Quebec, Canada (G.M.-G., E.M.J., J.-L.R.)
| |
Collapse
|
16
|
Iaconelli A, Pellicori P, Dolce P, Busti M, Ruggio A, Aspromonte N, D'Amario D, Galli M, Princi G, Caiazzo E, Rezig AOM, Maffia P, Pecorini G, Crea F, Cleland JGF. Coronary revascularization for heart failure with coronary artery disease: A systematic review and meta-analysis of randomized trials. Eur J Heart Fail 2023; 25:1094-1104. [PMID: 37211964 DOI: 10.1002/ejhf.2911] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Revised: 05/09/2023] [Accepted: 05/11/2023] [Indexed: 05/23/2023] Open
Abstract
AIMS Coronary artery disease (CAD) is a common cause of heart failure (HF). Whether coronary revascularization improves outcomes in patients with HF receiving guideline-recommended pharmacological therapy (GRPT) remains uncertain; therefore, we conducted a systematic review and meta-analysis of relevant randomized controlled trials (RCTs). METHODS AND RESULTS We searched in public databases for RCTs published between 1 January 2001 and 22 November 2022, investigating the effects of coronary revascularization on morbidity and mortality in patients with chronic HF due to CAD. All-cause mortality was the primary outcome. We included five RCTs that enrolled, altogether, 2842 patients (most aged <65 years; 85% men; 67% with left ventricular ejection fraction ≤35%). Overall, compared to medical therapy alone, coronary revascularization was associated with a lower risk of all-cause mortality (hazard ratio [HR] 0.88, 95% confidence interval [CI] 0.79-0.99; p = 0.0278) and cardiovascular mortality (HR 0.80, 95% CI 0.70-0.93; p = 0.0024) but not the composite of hospitalization for HF or all-cause mortality (HR 0.87, 95% CI 0.74-1.01; p = 0.0728). There were insufficient data to show whether the effects of coronary artery bypass graft surgery or percutaneous coronary intervention were similar or differed. CONCLUSIONS For patients with chronic HF and CAD enrolled in RCTs, the effect of coronary revascularization on all-cause mortality was statistically significant but neither substantial (HR 0.88) nor robust (upper 95% CI close to 1.0). RCTs were not blinded, which may bias reporting of the cause-specific reasons for hospitalization and mortality. Further trials are required to determine which patients with HF and CAD obtain a substantial benefit from coronary revascularization by either coronary artery bypass graft surgery or percutaneous coronary intervention.
Collapse
Affiliation(s)
- Antonio Iaconelli
- School of Cardiovascular and Metabolic Health, University of Glasgow, Glasgow, UK
- Department of Cardiovascular Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Pierpaolo Pellicori
- School of Cardiovascular and Metabolic Health, University of Glasgow, Glasgow, UK
| | - Pasquale Dolce
- Department of Public Health, University of Naples Federico II, Naples, Italy
| | - Matteo Busti
- Department of Cardiovascular Sciences, Catholic University of the Sacred Heart, Rome, Italy
| | - Aureliano Ruggio
- Department of Cardiovascular Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Nadia Aspromonte
- Department of Cardiovascular Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Domenico D'Amario
- Department of Translational Medicine, University of Eastern Piedmont, Novara, Italy
- Division of Cardiology, Azienda Ospedaliero Universitaria 'Maggiore della Carità', Novara, Italy
| | - Mattia Galli
- Maria Cecilia Hospital, GVM Care & Research, Cotignola, Italy
| | - Giuseppe Princi
- Department of Cardiovascular Sciences, Catholic University of the Sacred Heart, Rome, Italy
| | - Elisabetta Caiazzo
- Department of Pharmacy, School of Medicine and Surgery, University of Naples Federico II, Naples, Italy
- School of Infection and Immunity, College of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow, UK
| | - Asma O M Rezig
- School of Infection and Immunity, College of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow, UK
| | - Pasquale Maffia
- Department of Pharmacy, School of Medicine and Surgery, University of Naples Federico II, Naples, Italy
- School of Infection and Immunity, College of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow, UK
| | - Giovanni Pecorini
- Cardiovascular Internal Medicine Unit, Department of Cardiovascular Sciences, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Filippo Crea
- Department of Cardiovascular Sciences, Catholic University of the Sacred Heart, Rome, Italy
| | - John G F Cleland
- School of Cardiovascular and Metabolic Health, University of Glasgow, Glasgow, UK
| |
Collapse
|
17
|
Chen D, Schonberger AR, Ye K, Levsky JM. Coronary Calcium Predicts All-Cause Mortality in Suspected Acute Aortic Syndrome. Radiol Cardiothorac Imaging 2023; 5:e220188. [PMID: 37404788 PMCID: PMC10316301 DOI: 10.1148/ryct.220188] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2022] [Revised: 03/28/2023] [Accepted: 04/28/2023] [Indexed: 07/06/2023]
Abstract
PURPOSE To determine long-term clinical outcomes in patients with suspected acute aortic syndrome (AAS) and evaluate the prognostic value of coronary calcium burden as assessed with CT aortography in this symptomatic population. MATERIALS AND METHODS A retrospective cohort of all patients who underwent emergency CT aortography from January 2007 through January 2012 for suspected AAS was assembled. A medical record survey tool was used to evaluate subsequent clinical events over 10 years of follow-up. Events included death, aortic dissection, myocardial infarction, cerebrovascular accident, and pulmonary embolism. Coronary calcium scores were computed from original images using a validated simple 12-point ordinal method and categorized into none, low (1-3), moderate (4-6), or high (7-12) groupings. Survival analysis with Kaplan-Meier curves and Cox proportional hazard modeling was performed. RESULTS The study cohort comprised 1658 patients (mean age, 60 years ± 16 [SD]; 944 women), with 595 (35.9%) developing a clinical event over a median follow-up of 6.9 years. Patients with high coronary calcium demonstrated the highest mortality rate (adjusted hazard ratio = 2.36; 95% CI: 1.65, 3.37). Patients with low coronary calcium demonstrated lower mortality, but rates were still almost twice as high compared with patients with no detectable calcium (adjusted hazard ratio = 1.89; 95% CI: 1.41, 2.53). Coronary calcium was a strong predictor of major adverse cardiovascular events (P < .001), which persisted after adjustment for common significant comorbidities. CONCLUSION Patients with suspected AAS had a high rate of subsequent clinical events, including death. CT aortography-based coronary calcium scores strongly and independently predicted all-cause mortality.Keywords: Acute Aortic Syndrome, Coronary Artery Calcium, CT Aortography, Major Adverse Cardiovascular Events, Mortality Supplemental material is available for this article. © RSNA, 2023See also commentary by Weir-McCall and Shambrook in this issue.
Collapse
|
18
|
Pinto FJ, Piepoli MF, Ferrari R, Tsioufis K, Rosano GMC, Nedoshivin A, Kaski JC. Single-pill combination in the management of chronic coronary syndromes: A strategy to improve treatment adherence and patient outcomes? Int J Cardiol 2023:S0167-5273(23)00600-9. [PMID: 37116759 DOI: 10.1016/j.ijcard.2023.04.046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2023] [Accepted: 04/24/2023] [Indexed: 04/30/2023]
Abstract
Chronic coronary syndrome (CCS) represents a major challenge for physicians, particularly in the context of an increasing aging population. Additionally, CCS is often underestimated and under-recognised, particularly in female patients. As patients are frequently affected by several chronic comorbidities requiring polypharmacy, this can have a negative impact on patients' adherence to treatment. To overcome this barrier, single-pill combination (SPC), or fixed-dose combination, therapies are already widely used in the management of conditions such as hypertension, dyslipidaemia, and diabetes mellitus. The use of SPC anti-anginal therapy deserves careful consideration, as it has the potential to substantially improve treatment adherence and clinical outcomes, along with reducing the failure of pharmacological treatment before considering other interventions in patients with CCS.
Collapse
Affiliation(s)
- Fausto J Pinto
- Centro Academico de Medicina de Lisboa, CCUL, Faculdade de Medicina da Universidade de Lisboa, Lisbon, Portugal
| | - Massimo F Piepoli
- Clinical Cardiology, IRCCS Policlinico San Donato, Milan, Italy; Department of Biomedical Sciences for Health, University of Milan, Milan, Italy
| | - Roberto Ferrari
- Cardiology Center, University of Ferrara, Viale Aldo Moro 8, 44024 Cona, Ferrara, Italy; Maria Cecilia Hospital, GVM Care & Research, Cotignola, Ravenna, Italy
| | - Konstantinos Tsioufis
- 1st Department of Cardiology, National and Kapodistrian University of Athens, Hippokration Hospital, Greece
| | | | | | - Juan Carlos Kaski
- Molecular and Clinical Sciences Research Institute, St George's, University of London, UK.
| |
Collapse
|
19
|
Takura T, Komuro I, Ono M. Trends in the cost-effectiveness level of percutaneous coronary intervention: Macro socioeconomic analysis and health technology assessment. J Cardiol 2023; 81:356-363. [PMID: 36182005 DOI: 10.1016/j.jjcc.2022.09.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2022] [Accepted: 09/15/2022] [Indexed: 01/09/2023]
Abstract
Percutaneous coronary intervention (PCI), one of the most prevalent techniques of revascularization, is a procedure that remarkably improves treatment outcomes. However, it consumes large amounts of medical resources and has resulted in an increased socioeconomic burden due to the increasing number of target patients. In recent years, there have been sporadic discussions, both in Japan and other countries, regarding the optimization of interventions and the perspective of medical economics. Based on this, previous studies on PCI-related cost-effectiveness were reviewed in order to consider the current level of medical economics regarding PCI. Using the databases MEDLINE and EMBASE, a survey involving data from original articles and systematic reviews was conducted from January 2010 to August 2022. Conditions were not imposed on the evidence level due to the paucity of studies, although field studies were prioritized over simulation studies. The macro medical economics of acute myocardial infarction treatment, which is the primary target of PCI, were generally at an average level when compared to those in other countries; however, there is room for further improvement in Japan's performance. Revascularization in a population with multivessel coronary artery disease showed that coronary artery bypass graft surgery tended to be more cost-effective than PCI in the long-term setting. However, it was suggested that PCI may be more cost-effective in patients with SYNTAX Score ≤22 or left main artery disease. A cost-effectiveness report for stable angina patients was not in favor of PCI over medical therapy. Moreover, there were some reports showing the medical economic superiority of early myocardial ischemia evaluation, and it was foreseen that active selection of patients will contribute to the improvement of the overall cost-effectiveness of PCI. In order to further improve the socioeconomic significance of PCI in the future, it is necessary to aim for harmony between clinical practice and health economics.
Collapse
Affiliation(s)
- Tomoyuki Takura
- Department of Healthcare Economics and Health Policy, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan.
| | - Issei Komuro
- Department of Cardiovascular Medicine, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Minoru Ono
- Department of Cardiac Surgery, University of Tokyo Hospital, The University of Tokyo, Tokyo, Japan
| |
Collapse
|
20
|
Abstract
As society ages, the number of older adults with stable ischemic heart disease continues to rise. Older adults exhibit the greatest morbidity and mortality from stable angina. Furthermore, they suffer a higher burden of comorbidity and adverse events from treatment than younger patients. Given that older adults were excluded or underrepresented in most randomized controlled trials of stable ischemic heart disease, evidence for management is limited and hinges on subgroup analyses of trials and observational studies. This review aims to elucidate the current definitions of aging, assess the overall burden and clinical presentations of stable ischemic heart disease in older patients, weigh the available evidence for guideline-recommended treatment options including medical therapy and revascularization, and propose a framework for synthesizing complex treatment decisions in older adults with stable angina. Due to evolving goals of care in older patients, it is paramount to readdress the patient's priorities and preferences when deciding on treatment. Ultimately, the management of stable angina in older adults will need to be informed by dedicated studies in representative populations emphasizing patient-centered end points and person-centered decision-making.
Collapse
Affiliation(s)
- Michael G. Nanna
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, CT
| | - Stephen Y. Wang
- Department of Internal Medicine, Yale School of Medicine, New Haven, CT
| | - Abdulla A. Damluji
- Inova Center of Outcomes Research, Falls Church, VA
- Johns Hopkins University School of Medicine, Baltimore, MD
| |
Collapse
|
21
|
Hochman JS, Anthopolos R, Reynolds HR, Bangalore S, Xu Y, O’Brien SM, Mavromichalis S, Chang M, Contreras A, Rosenberg Y, Kirby R, Bhargava B, Senior R, Banfield A, Goodman SG, Lopes RD, Pracoń R, López-Sendón J, Maggioni AP, Newman JD, Berger JS, Sidhu MS, White HD, Troxel AB, Harrington RA, Boden WE, Stone GW, Mark DB, Spertus JA, Maron DJ. Survival After Invasive or Conservative Management of Stable Coronary Disease. Circulation 2023; 147:8-19. [PMID: 36335918 PMCID: PMC9797439 DOI: 10.1161/circulationaha.122.062714] [Citation(s) in RCA: 37] [Impact Index Per Article: 37.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2022] [Accepted: 10/26/2022] [Indexed: 11/09/2022]
Abstract
BACKGROUND The ISCHEMIA trial (International Study of Comparative Health Effectiveness With Medical and Invasive Approaches) compared an initial invasive versus an initial conservative management strategy for patients with chronic coronary disease and moderate or severe ischemia, with no major difference in most outcomes during a median of 3.2 years. Extended follow-up for mortality is ongoing. METHODS ISCHEMIA participants were randomized to an initial invasive strategy added to guideline-directed medical therapy or a conservative strategy. Patients with moderate or severe ischemia, ejection fraction ≥35%, and no recent acute coronary syndromes were included. Those with an unacceptable level of angina were excluded. Extended follow-up for vital status is being conducted by sites or through central death index search. Data obtained through December 2021 are included in this interim report. We analyzed all-cause, cardiovascular, and noncardiovascular mortality by randomized strategy, using nonparametric cumulative incidence estimators, Cox regression models, and Bayesian methods. Undetermined deaths were classified as cardiovascular as prespecified in the trial protocol. RESULTS Baseline characteristics for 5179 original ISCHEMIA trial participants included median age 65 years, 23% women, 16% Hispanic, 4% Black, 42% with diabetes, and median ejection fraction 0.60. A total of 557 deaths accrued during a median follow-up of 5.7 years, with 268 of these added in the extended follow-up phase. This included a total of 343 cardiovascular deaths, 192 noncardiovascular deaths, and 22 unclassified deaths. All-cause mortality was not different between randomized treatment groups (7-year rate, 12.7% in invasive strategy, 13.4% in conservative strategy; adjusted hazard ratio, 1.00 [95% CI, 0.85-1.18]). There was a lower 7-year rate cardiovascular mortality (6.4% versus 8.6%; adjusted hazard ratio, 0.78 [95% CI, 0.63-0.96]) with an initial invasive strategy but a higher 7-year rate of noncardiovascular mortality (5.6% versus 4.4%; adjusted hazard ratio, 1.44 [95% CI, 1.08-1.91]) compared with the conservative strategy. No heterogeneity of treatment effect was evident in prespecified subgroups, including multivessel coronary disease. CONCLUSIONS There was no difference in all-cause mortality with an initial invasive strategy compared with an initial conservative strategy, but there was lower risk of cardiovascular mortality and higher risk of noncardiovascular mortality with an initial invasive strategy during a median follow-up of 5.7 years. REGISTRATION URL: https://www. CLINICALTRIALS gov; Unique identifier: NCT04894877.
Collapse
Affiliation(s)
| | | | | | | | - Yifan Xu
- NYU Grossman School of Medicine, New York, NY, USA
| | | | | | | | | | | | - Ruth Kirby
- National Institutes of Health, Bethesda, MD, USA
| | | | - Roxy Senior
- Northwick Park Hospital, Harrow, London, UK
- Imperial College London and Royal Brompton Hospital, London, UK
| | | | - Shaun G. Goodman
- St. Michael’s Hospital, University of Toronto, Toronto, Ontario, Canada
| | | | - Radosław Pracoń
- Department of Coronary and Structural Heart Diseases, National Institute of Cardiology, Warsaw, Poland
| | - José López-Sendón
- IdiPaz Research Institute and Hospital Universitario La Paz, Madrid, Spain
| | | | | | | | | | - Harvey D. White
- Te Whatu Ora Health New Zealand, Te Toki Tumai, Green Lane Cardiovascular Services and University of Auckland, Auckland, NZ
| | | | | | - William E. Boden
- VA New England Healthcare System, Boston University School of Medicine, Boston, MA, USA
| | - Gregg W. Stone
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | | | - John A. Spertus
- Saint Luke’s Mid America Heart Institute and the University of Missouri, Kansas City, Kansas City, MO, USA
| | - David J. Maron
- Stanford University Department of Medicine, Stanford, CA, USA
| |
Collapse
|
22
|
Ueng KC, Chiang CE, Chao TH, Wu YW, Lee WL, Li YH, Ting KH, Su CH, Lin HJ, Su TC, Liu TJ, Lin TH, Hsu PC, Wang YC, Chen ZC, Jen HL, Lin PL, Ko FY, Yen HW, Chen WJ, Hou CJY. 2023 Guidelines of the Taiwan Society of Cardiology on the Diagnosis and Management of Chronic Coronary Syndrome. ACTA CARDIOLOGICA SINICA 2023; 39:4-96. [PMID: 36685161 PMCID: PMC9829849 DOI: 10.6515/acs.202301_39(1).20221103a] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 10/26/2022] [Accepted: 11/03/2022] [Indexed: 01/24/2023]
Abstract
Coronary artery disease (CAD) covers a wide spectrum from persons who are asymptomatic to those presenting with acute coronary syndromes (ACS) and sudden cardiac death. Coronary atherosclerotic disease is a chronic, progressive process that leads to atherosclerotic plaque development and progression within the epicardial coronary arteries. Being a dynamic process, CAD generally presents with a prolonged stable phase, which may then suddenly become unstable and lead to an acute coronary event. Thus, the concept of "stable CAD" may be misleading, as the risk for acute events continues to exist, despite the use of pharmacological therapies and revascularization. Many advances in coronary care have been made, and guidelines from other international societies have been updated. The 2023 guidelines of the Taiwan Society of Cardiology for CAD introduce a new concept that categorizes the disease entity according to its clinical presentation into acute or chronic coronary syndromes (ACS and CCS, respectively). Previously defined as stable CAD, CCS include a heterogeneous population with or without chest pain, with or without prior ACS, and with or without previous coronary revascularization procedures. As cardiologists, we now face the complexity of CAD, which involves not only the epicardial but also the microcirculatory domains of the coronary circulation and the myocardium. New findings about the development and progression of coronary atherosclerosis have changed the clinical landscape. After a nearly 50-year ischemia-centric paradigm of coronary stenosis, growing evidence indicates that coronary atherosclerosis and its features are both diagnostic and therapeutic targets beyond obstructive CAD. Taken together, these factors have shifted the clinicians' focus from the functional evaluation of coronary ischemia to the anatomic burden of disease. Research over the past decades has strengthened the case for prevention and optimal medical therapy as central interventions in patients with CCS. Even though functional capacity has clear prognostic implications, it does not include the evaluation of non-obstructive lesions, plaque burden or additional risk-modifying factors beyond epicardial coronary stenosis-driven ischemia. The recommended first-line diagnostic tests for CCS now include coronary computed tomographic angiography, an increasingly used anatomic imaging modality capable of detecting not only obstructive but also non-obstructive coronary plaques that may be missed with stress testing. This non-invasive anatomical modality improves risk assessment and potentially allows for the appropriate allocation of preventive therapies. Initial invasive strategies cannot improve mortality or the risk of myocardial infarction. Emphasis should be placed on optimizing the control of risk factors through preventive measures, and invasive strategies should be reserved for highly selected patients with refractory symptoms, high ischemic burden, high-risk anatomies, and hemodynamically significant lesions. These guidelines provide current evidence-based diagnosis and treatment recommendations. However, the guidelines are not mandatory, and members of the Task Force fully realize that the treatment of CCS should be individualized to address each patient's circumstances. Ultimately, the decision of healthcare professionals is most important in clinical practice.
Collapse
Affiliation(s)
- Kwo-Chang Ueng
- Division of Cardiology, Department of Internal Medicine, Chung Shan Medical University Hospital; School of Medicine, Chung Shan Medical University, Taichung
| | - Chern-En Chiang
- General Clinical Research Center and Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei
- School of Medicine, National Yang Ming Chiao Tung University, Taipei
| | - Ting-Hsing Chao
- Department of Internal Medicine, National Cheng Kung University Hospital; College of Medicine, National Cheng Kung University, Tainan
| | - Yen-Wen Wu
- School of Medicine, National Yang Ming Chiao Tung University, Taipei
- Division of Cardiology, Cardiovascular Medical Center, Far Eastern Memorial Hospital, New Taipei City
| | - Wen-Lieng Lee
- School of Medicine, National Yang Ming Chiao Tung University, Taipei
- Cardiovascular Center, Taichung Veterans General Hospital, Taichung
| | - Yi-Heng Li
- Department of Internal Medicine, National Cheng Kung University Hospital; College of Medicine, National Cheng Kung University, Tainan
| | - Ke-Hsin Ting
- Division of Cardiology, Department of Internal Medicine, Yunlin Christian Hospital, Yunlin
| | - Chun-Hung Su
- Division of Cardiology, Department of Internal Medicine, Chung Shan Medical University Hospital; School of Medicine, Chung Shan Medical University, Taichung
| | - Hung-Ju Lin
- Cardiovascular Center, Department of Internal Medicine, National Taiwan University Hospital
| | - Ta-Chen Su
- Cardiovascular Center, Department of Internal Medicine, National Taiwan University Hospital
- Department of Environmental and Occupational Medicine, National Taiwan University College of Medicine, Taipei
| | - Tsun-Jui Liu
- Cardiovascular Center, Taichung Veterans General Hospital, Taichung
| | - Tsung-Hsien Lin
- Division of Cardiology, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung
| | - Po-Chao Hsu
- Division of Cardiology, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung
| | - Yu-Chen Wang
- Division of Cardiology, Asia University Hospital, Department of Medical Laboratory Science and Biotechnology, Asia University, Taichung
| | - Zhih-Cherng Chen
- Division of Cardiology, Department of Internal Medicine, Chi-Mei Medical Center, Tainan
| | - Hsu-Lung Jen
- Division of Cardiology, Cheng Hsin Rehabilitation Medical Center, Taipei
| | - Po-Lin Lin
- Division of Cardiology, Hsinchu MacKay Memorial Hospital, Hsinchu
| | - Feng-You Ko
- Cardiovascular Center, Kaohsiung Veterans General Hospital, Kaohsiung
| | - Hsueh-Wei Yen
- Division of Cardiology, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung
| | - Wen-Jone Chen
- Division of Cardiology, Department of Internal Medicine, Min Sheng General Hospital, Taoyuan
| | - Charles Jia-Yin Hou
- Cardiovascular Center, Department of Internal Medicine, MacKay Memorial Hospital; Department of Medicine, Mackay Medical College, New Taipei City, Taiwan
| |
Collapse
|
23
|
Georgiopoulos G, Mavraganis G, Aimo A, Giorgetti A, Cavaleri S, Fabiani I, Giannoni A, Emdin M, Gimelli A. Sex-specific associations of myocardial perfusion imaging with outcomes in patients with suspected chronic coronary syndrome. Hellenic J Cardiol 2022; 71:8-15. [PMID: 36566838 DOI: 10.1016/j.hjc.2022.12.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2022] [Revised: 12/14/2022] [Accepted: 12/16/2022] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Myocardial perfusion scintigraphy (MPS) is an established diagnostic technique for inducible ischemia in patients with suspected chronic coronary syndrome (CCS). Some MPS findings, most notably an ischemia extent>10% of the left ventricle (LV), hold prognostic significance and support maximization of anti-ischemic treatment. We aimed to assess sex-specific associations of MPS findings with cardiovascular (CV) events in a population at high risk of CCS. METHODS In a prospective cohort study, 1,229 consecutive patients (age 70 ± 9.5 years, 73.5% males) without known CCS were referred to stress-rest MPS. All patients were followed for a median of 4.6 years for CV events. RESULTS Men and women had comparable risk profiles and incidence rates of CV events (6.6% vs. 4.6% respectively, P = 0.186). A summed stress score (SSS) > 7 was associated with the primary endpoint, including CV death and/or nonfatal myocardial infarction (MI) (adjusted hazard ratio [HR], 3.13; 95% confidence interval [CI], 1.79-5.46; P = 0.001), all-cause mortality (HR, 3.01; 95% CI, 1.31-6.93; P = 0.01), and incidence of late revascularization (HR, 1.84; 95% CI, 1.22-2.78; P = 0.004) in men but not women. A summed difference score (SDS) > 6 was related to a higher rate of the primary endpoint only in men (adjusted HR, 1.97; 95% CI, 1.18-3.30; P = 0.009). CONCLUSIONS Among patients undergoing a diagnostic workup for suspected CCS, stress perfusion and reversible ischemia abnormalities may independently predict worse survival and more CV events in men. However, the obtained results indicated the need for sex-specific cutoffs to refine risk stratification and assist in clinical decisions on anti-ischemic therapy beyond coronary artery anatomy.
Collapse
Affiliation(s)
- Georgios Georgiopoulos
- Fondazione Toscana Gabriele Monasterio, Via Giuseppe Moruzzi, 1, 56124, Pisa, Italy; Department of Clinical Therapeutics, National and Kapodistrian University of Athens, Vasilissis Sofias 80 str, 11528, Athens, Greece; School of Biomedical Engineering and Imaging Sciences, King's College, Strand, London WC2R 2LS, London, UK.
| | - Georgios Mavraganis
- Department of Clinical Therapeutics, National and Kapodistrian University of Athens, Vasilissis Sofias 80 str, 11528, Athens, Greece
| | - Alberto Aimo
- Fondazione Toscana Gabriele Monasterio, Via Giuseppe Moruzzi, 1, 56124, Pisa, Italy; Scuola Superiore Sant'Anna, Piazza Martiri della Libertà, 33, 56127 Pisa, Italy
| | - Assuero Giorgetti
- Fondazione Toscana Gabriele Monasterio, Via Giuseppe Moruzzi, 1, 56124, Pisa, Italy
| | - Samuele Cavaleri
- Fondazione Toscana Gabriele Monasterio, Via Giuseppe Moruzzi, 1, 56124, Pisa, Italy
| | - Iacopo Fabiani
- Fondazione Toscana Gabriele Monasterio, Via Giuseppe Moruzzi, 1, 56124, Pisa, Italy
| | - Alberto Giannoni
- Fondazione Toscana Gabriele Monasterio, Via Giuseppe Moruzzi, 1, 56124, Pisa, Italy
| | - Michele Emdin
- Fondazione Toscana Gabriele Monasterio, Via Giuseppe Moruzzi, 1, 56124, Pisa, Italy; Scuola Superiore Sant'Anna, Piazza Martiri della Libertà, 33, 56127 Pisa, Italy
| | - Alessia Gimelli
- Fondazione Toscana Gabriele Monasterio, Via Giuseppe Moruzzi, 1, 56124, Pisa, Italy
| |
Collapse
|
24
|
Mavromatis K, Boden WE, Maron DJ, Mancini GBJ, Weintraub WS, Gosselin G, Berman DS, Shaw LJ, Spertus JA, Hochman JS. Comparison of Outcomes of Invasive or Conservative Management of Chronic Coronary Disease in Four Randomized Controlled Trials. Am J Cardiol 2022; 185:18-28. [PMID: 36257844 DOI: 10.1016/j.amjcard.2022.09.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2022] [Revised: 08/17/2022] [Accepted: 09/09/2022] [Indexed: 01/09/2023]
Abstract
Revascularization and medical therapy for chronic coronary disease have both evolved significantly over the last 50 years. A total of 4 contemporary randomized controlled trials- Clinical Outcomes Utilizing Revascularization and Aggressive drug Evaluation (COURAGE), Bypass Angioplasty Revascularization Investigation 2 Diabetes (BARI 2D), Fractional Flow Reserve versus Angiography for Multivessel Evaluation 2 (FAME 2), and International Study of Comparative Health Effectiveness with Medical and Invasive Approaches (ISCHEMIA)-have assessed the incremental benefit of revascularization when added to secondary prevention with intensive pharmacologic and lifestyle intervention. We reviewed these 4 seminal studies with the objective of marshaling evidence to better frame how these results should apply to clinical decision making. These studies differed in study design, end points, intensity of treatment, and revascularization techniques. Nevertheless, they all demonstrate similar rates of "hard" clinical events with invasive and conservative management, and varying degrees of benefit in angina-related quality of life with revascularization. In conclusion, although controversy persists concerning the role of revascularization because of differing interpretations of the clinical trial evidence, we contend that instead of being competing management strategies, invasive and conservative approaches are complementary.
Collapse
Affiliation(s)
- Kreton Mavromatis
- Division of Cardiology, Atlanta VA Health Care System, Atlanta, Georgia; Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia.
| | - William E Boden
- Department of Medicine, VA New England Healthcare System, Boston University School of Medicine, Boston, Massachusetts
| | - David J Maron
- Stanford Prevention Research Center, Division of Cardiovascular Medicine, Department of Medicine, Stanford University School of Medicine, Stanford, California
| | - G B John Mancini
- Department of Medicine, Division of Cardiology, Center for Cardiovascular Innovation, University of British Columbia, Vancouver, British Columbia, Canada
| | - William S Weintraub
- MedStar Health and Department of Medicine, MedStar Health Research Institute, Georgetown University, Washington, District of Columbia
| | - Gilbert Gosselin
- Department of Medicine, Montreal Heart Institute, Montreal, Québec, Canada
| | - Daniel S Berman
- Division of Cardiology, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, California
| | - Leslee J Shaw
- Icahn School of Medicine at Mt Sinai, New York, New York
| | - John A Spertus
- Department of Medicine, Saint Luke's Mid America Heart Institute, University of Missouri - Kansas City, Kansas City, Missouri
| | - Judith S Hochman
- Division of Cardiology, Department of Medicine, New York University Grossman School of Medicine, New York, New York
| |
Collapse
|
25
|
Wagener M, Boeddinghaus J, Gaemperli O, Räber L, Nietlispach F, Meier P, Muller O, Weilenmann D, Jeger R. Trends in Coronary and Structural Heart Interventions in Switzerland over the Last 16 Years and Impact of COVID-19: Insights from the National Swiss PCI Survey. J Clin Med 2022; 11:jcm11247459. [PMID: 36556075 PMCID: PMC9783484 DOI: 10.3390/jcm11247459] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2022] [Revised: 12/04/2022] [Accepted: 12/10/2022] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Considering the global burden of cardiovascular disease, we analysed trends in interventional coronary and structural procedures over the past 16 years (2005-2021), using continuous data from the Swiss national registry. METHODS Based on a standardised questionnaire, data on coronary and structural interventions in Switzerland were assessed by the Working Group Interventional Cardiology of the Swiss Society of Cardiology (SSC). Here, we analysed the trend of annually performed interventions from 2005 to 2021 in Switzerland and the impact of the COVID-19 pandemic. RESULTS We observed a constant increase in the total number of cases (including coronary angiographies (CA) and percutaneous coronary interventions (PCI)) from 36,436 cases in 2005 to 56,555 cases in 2021 (+55%). With 18 cases in 2007, TAVI procedures have increased to 2004 cases in 2021. During the early phase of the COVID-19 pandemic in 2020, a slight decrease in CAs and PCIs of 9.15% was observed. In contrast, we did not observe an impact of the COVID-19 pandemic on the number of no TAVI procedures. Most importantly, all cause in-hospital mortality for coronary interventions before and during the peak of the COVID-19 pandemic was comparable (1.4% vs. 1.3%). CONCLUSION Over a 16-year period, we observed an upward trend in diagnostic and therapeutic procedures for coronary as well as structural heart disease, with only a small short-term impact of the COVID-19 pandemic on interventions and a similar procedure-related in-hospital-mortality in Switzerland.
Collapse
Affiliation(s)
- Max Wagener
- Department of Cardiology, Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, 4031 Basel, Switzerland
- Department of Cardiology, University Hospital Galway, H91 YR71 Galway, Ireland
| | - Jasper Boeddinghaus
- Department of Cardiology, Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, 4031 Basel, Switzerland
- BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh EH16 4TJ, UK
| | - Oliver Gaemperli
- Department of Cardiology, Heart Clinic Hirslanden, 8032 Zurich, Switzerland
| | - Lorenz Räber
- Department of Cardiology, Bern University Hospital, 3010 Bern, Switzerland
| | - Fabian Nietlispach
- Heart Centre Im Park, Hirslanden Clinic Im Park, 8027 Zurich, Switzerland
| | - Pascal Meier
- Cantonal Hospital Freiburg, 1752 Villars-sur-Glâne, Switzerland
| | - Olivier Muller
- Department of Cardiology, University Hospital Vaud, 1011 Lausanne, Switzerland
| | | | - Raban Jeger
- Department of Cardiology, Triemli Hospital Zurich, 8063 Zurich, Switzerland
- Faculty of Medicine, University of Basel, 4001 Basel, Switzerland
- Correspondence:
| |
Collapse
|
26
|
Improving Detection of CAD and Prognosis with PET/CT Quantitative Absolute Myocardial Blood Flow Measurements. Curr Cardiol Rep 2022; 24:1855-1864. [PMID: 36348147 DOI: 10.1007/s11886-022-01805-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/11/2022] [Indexed: 11/10/2022]
Abstract
PURPOSE OF REVIEW The purpose of this review is to provide an overview of the role of PET MPI in the detection of CAD, focussing on the added value of MBF for diagnosis and prognostication. RECENT FINDINGS Positron emission tomography (PET) myocardial perfusion imaging (MPI) is increasingly used for the risk stratification of patients with suspected or established coronary artery disease (CAD). PET MPI provides accurate and reproducible non-invasive quantification of myocardial blood flow (MBF) at rest and during hyperemia, providing incremental information over conventional myocardial perfusion alone. Inclusion of MBF in PET MPI interpretation improves both its sensitivity and specificity. Moreover, quantitative MBF measurements have repeatedly been shown to offer incremental and independent prognostic information over conventional clinical markers in a broad range of conditions, including in CAD. Quantitative MBF measurement is now an established and powerful tool enabling accurate risk stratification and guiding patients' management. The role of PET MPI and flow quantification in cardiac allograft vasculopathy (CAV), which represents a particular form of CAD, will also be reviewed.
Collapse
|
27
|
Smilowitz NR, Carey EP, Shah B, Hartigan PM, Plomondon ME, Maron DJ, Maddox TM, Spertus JA, Mancini GBJ, Chaitman BR, Weintraub WS, Sedlis SP, Boden WE. Comparison of Characteristics and Outcomes of Veterans With Stable Ischemic Heart Disease Enrolled in the COURAGE Trial Versus the Veterans Affairs Clinical Assessment, Reporting, and Tracking Program. Am J Cardiol 2022; 180:1-9. [PMID: 35918234 PMCID: PMC10019948 DOI: 10.1016/j.amjcard.2022.06.049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2022] [Revised: 06/19/2022] [Accepted: 06/22/2022] [Indexed: 11/29/2022]
Abstract
Randomized clinical trials have not demonstrated a survival benefit with percutaneous coronary intervention in stable ischemic heart disease (SIHD). We evaluated the generalizability of the COURAGE (Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation) trial findings to the broader population of veterans with SIHD. Veterans who underwent coronary angiography between 2005 and 2013 for SIHD were identified from the Veterans Affairs Clinical Assessment, Reporting and Tracking Program (VA CART). Patient-level comparisons were made between patients from VA CART who met the eligibility criteria for COURAGE and veterans enrolled in COURAGE between 1999 and 2004. All-cause mortality over long-term follow-up was assessed using Cox proportional hazards models. COURAGE-eligible patients from VA CART (n = 59,758) were older, had a higher body mass index, a greater prevalence of co-morbidities, but fewer diseased vessels on index coronary angiography, and were less likely to be on optimal medical therapy at baseline and on 1-year follow-up compared with VA COURAGE participants (n = 968). Patients from VA CART (median follow-up 6.5 years) had higher all-cause mortality (adjusted hazard ratio [aHR] 1.98 [1.61 to 2.43]) than participants from VA COURAGE (median follow-up: 4.6 years). Risks of mortality were greater in the 56.4% patients from CART who were medically managed (aHR 1.94 [1.49 to 2.53]) and in the 43.6% who underwent percutaneous coronary intervention (aHR 1.99 [1.45 to 2.74]), compared with their respective VA COURAGE arms. In conclusion, in this noncontemporaneous patient-level analysis, veterans in the randomized COURAGE trial had more favorable outcomes than the population of veterans with SIHD at large.
Collapse
Affiliation(s)
- Nathaniel R Smilowitz
- Cardiology Section, Department of Medicine, VA New York Healthcare Network, New York, New York; Division of Cardiology, Department of Medicine, NYU School of Medicine, New York, New York
| | - Evan P Carey
- Rocky Mountain Regional VA Medical Center, Aurora, Colorado
| | - Binita Shah
- Cardiology Section, Department of Medicine, VA New York Healthcare Network, New York, New York; Division of Cardiology, Department of Medicine, NYU School of Medicine, New York, New York.
| | | | - Mary E Plomondon
- CART Program, Office of Quality and Patient Safety, Veterans Health Administration, Washington, District of Columbia
| | - David J Maron
- Stanford University School of Medicine, Stanford, California
| | - Thomas M Maddox
- Division of Cardiology, Washington University School of Medicine, St. Louis, Missouri
| | - John A Spertus
- Mid-America Heart Institute, University of Missouri, Kansas City, Kansas City, Missouri
| | - G B John Mancini
- Centre for Cardiovascular Innovation, Vancouver Hospital, Vancouver, British Canada, Canada
| | | | - William S Weintraub
- MedStar Health Research Institute, Georgetown University, Washington, District of Columbia
| | - Steven P Sedlis
- Cardiology Section, Department of Medicine, VA New York Healthcare Network, New York, New York; Division of Cardiology, Department of Medicine, NYU School of Medicine, New York, New York
| | | |
Collapse
|
28
|
Rashid M, Stevens C, Wijeysundera HC, Curzen N, Khoo CW, Mohamed MO, Aktaa S, Wu J, Ludman P, Mamas MA. Rates of Elective Percutaneous Coronary Intervention in England and Wales: Impact of COURAGE and ORBITA Trials. J Am Heart Assoc 2022; 11:e025426. [DOI: 10.1161/jaha.122.025426] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Background
There are limited data about how COURAGE (Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation) and ORBITA (Objective Randomized Blinded Investigation With Optimal Medical Therapy of Angioplasty in Stable Angina) trials have impacted percutaneous coronary intervention (PCI) practices at regional or national level. We evaluated temporal trends in elective PCI rates for stable angina and, specifically, examined the impact of the COURAGE and ORBITA trials on PCI practices in England and Wales.
Methods and Results
We used national PCI data comprising >1.2 million patients undergoing PCI between January 2006 and December 2019. Patient demographics, procedural details, and clinical outcomes were analyzed, and temporal trends in PCI rates for stable angina were compared before and after the publication of the COURAGE and ORBITA trials. Of 1 245 802 PCI procedures, 430 248 (34.5%) were performed for stable angina. Over the study period, the number of elective PCI procedures per year (30 823 in 2006 to 34 103 in 2019) and per 100 000 population estimates (50.7 in 2006 to 58.4 in 2019) remained stable. The proportion of patients undergoing elective PCI without angina symptoms almost doubled from 5.1% to 9.7%. The incidence rate of elective PCI volume after the COURAGE trial, published in 2007, was not different from before the trial was published (incidence rate ratio, 1.06 [95% CI, 0.69–1.62]). It also remained stable after the publication of the ORBITA trial in 2017 (incidence rate ratio, 0.96 [95% CI, 0.74–1.23]).
Conclusions
In this nationwide analysis, rates of elective PCI for stable angina remained stable over 14 years. Publication of the COURAGE and ORBITA trials had no impact on elective PCI activity.
Collapse
Affiliation(s)
- Muhammad Rashid
- Keele Cardiovascular Research Group, School of Medicine, Keele University Stoke‐on‐Trent UK
- Department of Academic Cardiology Royal Stoke University Hospital Stoke‐on‐Trent UK
| | - Chris Stevens
- Keele Cardiovascular Research Group, School of Medicine, Keele University Stoke‐on‐Trent UK
| | | | - Nick Curzen
- Faculty of Medicine, University of Southampton & Department of Cardiology University Hospital NHS Trust Southampton UK
| | - Chee Wah Khoo
- Department of Academic Cardiology Royal Stoke University Hospital Stoke‐on‐Trent UK
| | - Mohamed Osama Mohamed
- Keele Cardiovascular Research Group, School of Medicine, Keele University Stoke‐on‐Trent UK
| | - Suleman Aktaa
- Leeds Institute for Data Analytics, Leeds Institute of Cardiovascular and Metabolic Medicine Leeds UK
| | - Jianhua Wu
- Leeds Institute for Data Analytics, Leeds Institute of Cardiovascular and Metabolic Medicine Leeds UK
- School of Dentistry University of Leeds UK
| | - Peter F. Ludman
- Department of Cardiology Queen Elizabeth University Hospital Birmingham UK
| | - Mamas A. Mamas
- Keele Cardiovascular Research Group, School of Medicine, Keele University Stoke‐on‐Trent UK
- Department of Academic Cardiology Royal Stoke University Hospital Stoke‐on‐Trent UK
| |
Collapse
|
29
|
Bittl JA, Tamis-Holland JE, Lawton JS. Does Bypass Surgery or Percutaneous Coronary Intervention Improve Survival in Stable Ischemic Heart Disease? JACC Cardiovasc Interv 2022; 15:1243-1248. [PMID: 35583361 DOI: 10.1016/j.jcin.2022.05.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2022] [Accepted: 05/05/2022] [Indexed: 11/18/2022]
Affiliation(s)
- John A Bittl
- Scientific Publishing Committee, American College of Cardiology, Washington, DC, USA.
| | | | - Jennifer S Lawton
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| |
Collapse
|
30
|
Jafary FH, Jafary AH. Ischemia Trial: Does the Cardiology Community Need to Pivot or Continue Current Practices? Curr Cardiol Rep 2022; 24:1059-1068. [PMID: 35653055 PMCID: PMC9161182 DOI: 10.1007/s11886-022-01725-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/19/2022] [Indexed: 11/30/2022]
Abstract
PURPOSE OF REVIEW For decades, the standard of care for stable ischemic heart disease (SIHD) has been an ischemia-centric approach based on largely observational data suggesting a survival benefit of revascularization in patients with moderate-or-severe ischemia. In this article, we will objectively review the evolution of the ischemia paradigm, the trial evidence comparing revascularization to medical therapy in SIHD, and what contemporary practice should be in 2022. RECENT FINDINGS Randomized trials, including COURAGE and, most recently, the ISCHEMIA trial, have shown no reduction in "hard outcomes" like death and myocardial infarction (MI) in SIHD compared to medical therapy. The trial excluded high-risk patients with left main disease, low ejection fraction (EF) < 35%, and severe unacceptable angina. Irrespective of the severity of ischemia and the extent of coronary artery disease (CAD), revascularization did not offer any prognostic advantage over medical therapy. On the other hand, there was a durable improvement in symptoms. While there are many caveats to the ISCHEMIA trial, the overall strengths of the trial outweigh these limitations. The findings of ISCHEMIA are consistent with previous trials. It is time for the cardiology community to pivot towards medical therapy as the initial step for most patients with SIHD. Physicians should have the "COURAGE" to embrace "ISCHEMIA" and be comfortable with treating ischemia medically.
Collapse
Affiliation(s)
- Fahim H Jafary
- Department of Cardiology NHG Heart Institute, Tan Tock Seng Hospital, 11 Jalan Tan Tock Seng, Singapore, 308433, Singapore.
| | - Ali H Jafary
- St. George's University School of Medicine, University Centre, St. George's, Grenada
| |
Collapse
|
31
|
Lee SH, Hong D, Dai N, Shin D, Choi KH, Kim SM, Kim HK, Jeon KH, Ha SJ, Lee KY, Park TK, Yang JH, Song YB, Hahn JY, Choi SH, Choe YH, Gwon HC, Ge J, Lee JM. Anatomic and Hemodynamic Plaque Characteristics for Subsequent Coronary Events. Front Cardiovasc Med 2022; 9:871450. [PMID: 35677691 PMCID: PMC9167998 DOI: 10.3389/fcvm.2022.871450] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Accepted: 04/19/2022] [Indexed: 11/13/2022] Open
Abstract
ObjectivesWhile coronary computed tomography angiography (CCTA) enables the evaluation of anatomic and hemodynamic plaque characteristics of coronary artery disease (CAD), the clinical roles of these characteristics are not clear. We sought to evaluate the prognostic implications of CCTA-derived anatomic and hemodynamic plaque characteristics in the prediction of subsequent coronary events.MethodsThe study cohort consisted of 158 patients who underwent CCTA with suspected CAD within 6–36 months before percutaneous coronary intervention (PCI) for acute myocardial infarction (MI) or unstable angina and age-/sex-matched 62 patients without PCI as the control group. Preexisting high-risk plaque characteristics (HRPCs: low attenuation plaque, positive remodeling, napkin-ring sign, spotty calcification, minimal luminal area <4 mm2, or plaque burden ≥70%) and hemodynamic parameters (per-vessel fractional flow reserve [FFRCT], per-lesion ΔFFRCT, and percent ischemic myocardial mass) were analyzed from prior CCTA. The primary outcome was a subsequent coronary event, which was defined as a composite of vessel-specific MI or revascularization for unstable angina. The prognostic impact of clinical risk factors, HRPCs, and hemodynamic parameters were compared between vessels with (160 vessels) and without subsequent coronary events (329 vessels).ResultsVessels with a subsequent coronary event had higher number of HRPCs (2.6 ± 1.4 vs. 2.3 ± 1.4, P = 0.012), lower FFRCT (0.76 ± 0.13 vs. 0.82 ± 0.11, P < 0.001), higher ΔFFRCT (0.14 ± 0.12 vs. 0.09 ± 0.08, P < 0.001), and higher percent ischemic myocardial mass (29.0 ± 18.5 vs. 26.0 ± 18.4, P = 0.022) than those without a subsequent coronary event. Compared with clinical risk factors, HRPCs and hemodynamic parameters showed higher discriminant abilities for subsequent coronary events with ΔFFRCT being the most powerful predictor. HRPCs showed additive discriminant ability to clinical risk factors (c-index 0.620 vs. 0.558, P = 0.027), and hemodynamic parameters further increased discriminant ability (c-index 0.698 vs. 0.620, P = 0.001) and reclassification abilities (NRI 0.460, IDI 0.061, P < 0.001 for all) for subsequent coronary events. Among vessels with negative FFRCT (>0.80), adding HRPCs into clinical risk factors significantly increased discriminant and reclassification abilities for subsequent coronary events (c-index 0.687 vs. 0.576, P = 0.005; NRI 0.412, P = 0.002; IDI 0.064, P = 0.001) but not for vessels with positive FFRCT (≤0.80).ConclusionIn predicting subsequent coronary events, both HRPCs and hemodynamic parameters by CCTA allow better prediction of subsequent coronary events than clinical risk factors. HRPCs provide more incremental predictability than clinical risk factors alone among vessels with negative FFRCT but not among vessels with positive FFRCT.Clinical Trial RegistrationPreDiction and Validation of Clinical CoursE of Coronary Artery DiSease With CT-Derived Non-INvasive HemodYnamic Phenotyping and Plaque Characterization (DESTINY Study), NCT04794868.
Collapse
Affiliation(s)
- Seung Hun Lee
- Division of Cardiology, Department of Internal Medicine, Chonnam National University Hospital, Chonnam National University Medical School, Gwangju, South Korea
| | - David Hong
- Division of Cardiology, Department of Internal Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Neng Dai
- Department of Cardiology, Shanghai Institute of Cardiovascular Diseases, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Doosup Shin
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, IA, United States
| | - Ki Hong Choi
- Division of Cardiology, Department of Internal Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Sung Mok Kim
- Department of Radiology, Cardiovascular Imaging Center, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Hyun Kuk Kim
- Department of Internal Medicine and Cardiovascular Center, Chosun University Hospital, University of Chosun College of Medicine, Gwangju, South Korea
| | - Ki-Hyun Jeon
- Division of Cardiovascular Medicine, Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, South Korea
| | - Sang Jin Ha
- Division of Cardiology, Department of Internal Medicine, Gangneung Asan Hospital, University of Ulsan College of Medicine, Gangneung, South Korea
| | - Kwan Yong Lee
- Cardiovascular Center and Cardiology Division, Seoul St. Mary's Hospital, The Catholic University of Korea, Seoul, South Korea
| | - Taek Kyu Park
- Division of Cardiology, Department of Internal Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Jeong Hoon Yang
- Division of Cardiology, Department of Internal Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Young Bin Song
- Division of Cardiology, Department of Internal Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Joo-Yong Hahn
- Division of Cardiology, Department of Internal Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Seung-Hyuk Choi
- Division of Cardiology, Department of Internal Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Yeon Hyeon Choe
- Department of Radiology, Cardiovascular Imaging Center, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Hyeon-Cheol Gwon
- Division of Cardiology, Department of Internal Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Junbo Ge
- Department of Cardiology, Shanghai Institute of Cardiovascular Diseases, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Joo Myung Lee
- Division of Cardiology, Department of Internal Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
- *Correspondence: Joo Myung Lee ;
| |
Collapse
|
32
|
Weintraub WS. Revascularization for stable ischemic heart disease: the beat goes on. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2022; 40:48-49. [DOI: 10.1016/j.carrev.2022.04.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2022] [Accepted: 04/25/2022] [Indexed: 11/26/2022]
|
33
|
Wang J, Wang S, Zhu MX, Yang T, Yin Q, Hou Y. Risk Prediction of Major Adverse Cardiovascular Events Occurrence Within 6 Months After Coronary Revascularization: Machine Learning Study. JMIR Med Inform 2022; 10:e33395. [PMID: 35442202 PMCID: PMC9069286 DOI: 10.2196/33395] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2021] [Revised: 02/25/2022] [Accepted: 03/02/2022] [Indexed: 12/13/2022] Open
Abstract
Background As a major health hazard, the incidence of coronary heart disease has been increasing year by year. Although coronary revascularization, mainly percutaneous coronary intervention, has played an important role in the treatment of coronary heart disease, major adverse cardiovascular events (MACE) such as recurrent or persistent angina pectoris after coronary revascularization remain a very difficult problem in clinical practice. Objective Given the high probability of MACE after coronary revascularization, the aim of this study was to develop and validate a predictive model for MACE occurrence within 6 months based on machine learning algorithms. Methods A retrospective study was performed including 1004 patients who had undergone coronary revascularization at The People’s Hospital of Liaoning Province and Affiliated Hospital of Liaoning University of Traditional Chinese Medicine from June 2019 to December 2020. According to the characteristics of available data, an oversampling strategy was adopted for initial preprocessing. We then employed six machine learning algorithms, including decision tree, random forest, logistic regression, naïve Bayes, support vector machine, and extreme gradient boosting (XGBoost), to develop prediction models for MACE depending on clinical information and 6-month follow-up information. Among all samples, 70% were randomly selected for training and the remaining 30% were used for model validation. Model performance was assessed based on accuracy, precision, recall, F1-score, confusion matrix, area under the receiver operating characteristic (ROC) curve (AUC), and visualization of the ROC curve. Results Univariate analysis showed that 21 patient characteristic variables were statistically significant (P<.05) between the groups without and with MACE. Coupled with these significant factors, among the six machine learning algorithms, XGBoost stood out with an accuracy of 0.7788, precision of 0.8058, recall of 0.7345, F1-score of 0.7685, and AUC of 0.8599. Further exploration of the models to identify factors affecting the occurrence of MACE revealed that use of anticoagulant drugs and course of the disease consistently ranked in the top two predictive factors in three developed models. Conclusions The machine learning risk models constructed in this study can achieve acceptable performance of MACE prediction, with XGBoost performing the best, providing a valuable reference for pointed intervention and clinical decision-making in MACE prevention.
Collapse
Affiliation(s)
- Jinwan Wang
- School of Information Management, Nanjing University, Nanjing, China
| | - Shuai Wang
- First Department of Cardiology, The Affiliated Hospital of Liaoning University of Traditional Chinese Medicine, Shenyang, China
| | - Mark Xuefang Zhu
- School of Information Management, Nanjing University, Nanjing, China
| | - Tao Yang
- School of Artificial Intelligence and Information Technology, Nanjing University of Chinese Medicine, Nanjing, China
| | - Qingfeng Yin
- Jiangsu Famous Medical Technology Co Ltd, Nanjing, China
| | - Ya Hou
- Jiangsu Famous Medical Technology Co Ltd, Nanjing, China
| |
Collapse
|
34
|
Ruel M, Williams A, Ouzounian M, Sun L, Légaré JF, Poirier P, Malas T, Farkouh ME, Chedrawy E, Hassan A, Higgins J, Connelly K, McClure RS, Bewick D, Whitlock R, Graham M, Arora RC. Missing the Goal with the 2021 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization. Can J Cardiol 2022; 38:705-708. [PMID: 35341903 DOI: 10.1016/j.cjca.2022.03.013] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2022] [Revised: 03/13/2022] [Accepted: 03/20/2022] [Indexed: 11/26/2022] Open
Affiliation(s)
- Marc Ruel
- Division of Cardiac Surgery, University of Ottawa Heart Institute, Ottawa, ON.
| | - Anne Williams
- Division of Cardiology, Department of Medicine, Memorial University, St. John's, NL
| | - Maral Ouzounian
- Division of Cardiovascular Surgery, Peter Munk Cardiac Centre, University Health Network, University of Toronto, ON
| | - Louise Sun
- Division of Cardiac Anesthesiology, University of Ottawa Heart Institute, Ottawa, ON
| | | | - Paul Poirier
- Faculté de pharmacie, Université Laval, Institut universitaire de cardiologie et de pneumologie de Québec, QC
| | - Tarek Malas
- Département de Chirurgie, Université Laval, Institut universitaire de cardiologie et de pneumologie de Québec, QC
| | - Michael E Farkouh
- Peter Munk Cardiac Centre and Heart and Stroke Richard Lewar Centre, University of Toronto, ON
| | - Edgar Chedrawy
- Division of Cardiac Surgery, QEII Health Sciences Centre, Halifax, NS
| | - Ansar Hassan
- Department of Cardiovascular Surgery, Maine Medical Center, Portland, Maine, USA
| | - Jennifer Higgins
- Division of Cardiac Surgery, St. Mary's General Hospital, Kitchener, ON
| | - Kim Connelly
- Keenan Research Centre for Biomedical Science, UnityHealth, University of Toronto, ON
| | - R Scott McClure
- Department of Cardiac Sciences, Section of Cardiac Surgery, Libin Cardiovascular Institute, University of Calgary, AB
| | - David Bewick
- Department of Medicine, New Brunswick Heart Center, Saint John, NB
| | | | - Michelle Graham
- Department of Medicine and Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, AB
| | - Rakesh C Arora
- Department of Surgery, Section of Cardiac Surgery, Max Rady College of Medicine, University of Manitoba, MB
| |
Collapse
|
35
|
Nakano S, Kohsaka S, Chikamori T, Fukushima K, Kobayashi Y, Kozuma K, Manabe S, Matsuo H, Nakamura M, Ohno T, Sawano M, Toda K, Ueda Y, Yokoi H, Gatate Y, Kasai T, Kawase Y, Matsumoto N, Mori H, Nakazato R, Niimi N, Saito Y, Shintani A, Watanabe I, Watanabe Y, Ikari Y, Jinzaki M, Kosuge M, Nakajima K, Kimura T. JCS 2022 Guideline Focused Update on Diagnosis and Treatment in Patients With Stable Coronary Artery Disease. Circ J 2022; 86:882-915. [DOI: 10.1253/circj.cj-21-1041] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Affiliation(s)
- Shintaro Nakano
- Cardiology, Saitama Medical University International Medical Center
| | | | | | - Kenji Fukushima
- Department of Radiology and Nuclear Medicine, Fukushima Medical University
| | | | - Ken Kozuma
- Cardiology, Teikyo University School of Medicine
| | - Susumu Manabe
- Cardiac Surgery, International University of Health and Welfare Mita Hospital
| | | | - Masato Nakamura
- Cardiovascular Medicine, Toho University Ohashi Medical Center
| | | | | | - Koichi Toda
- Cardiovascular Surgery, Osaka University Graduate School of Medicine
| | - Yasunori Ueda
- Cardiovascular Division, National Hospital Organization Osaka National Hospital
| | - Hiroyoshi Yokoi
- Cardiovascular Center, International University of Health and Welfare Fukuoka Sanno Hospital
| | - Yodo Gatate
- Cardiology, Self-Defense Forces Central Hospital
| | | | | | | | - Hitoshi Mori
- Cardiology, Saitama Medical University International Medical Center
| | | | | | - Yuichi Saito
- Cardiovascular Medicine, Chiba University School of Medicine
| | - Ayumi Shintani
- Medical Statistics, Osaka City University Graduate School of Medicine
| | - Ippei Watanabe
- Cardiovascular Medicine, Toho University School of Medicine
| | | | - Yuji Ikari
- Cardiology, Tokai University School of Medicine
| | | | | | - Kenichi Nakajima
- Functional Imaging and Artificial Intelligence, Kanazawa University
| | - Takeshi Kimura
- Cardiovascular Medicine, Kyoto University Graduate School of Medicine
| | | |
Collapse
|
36
|
Ohno T. The magnitude of the survival benefit of internal thoracic artery grafting: Absolute risk reduction. JTCVS OPEN 2022; 9:106-111. [PMID: 36003479 PMCID: PMC9390134 DOI: 10.1016/j.xjon.2021.11.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/08/2021] [Accepted: 11/12/2021] [Indexed: 11/22/2022]
Affiliation(s)
- Takayuki Ohno
- Address for reprints: Takayuki Ohno, MD, PhD, Department of Cardiovascular Surgery and Intensive Care Unit, Mitsui Memorial Hospital, 1 Kanda Izumicho, Chyoda-ku, Tokyo 101-8643, Japan.
| |
Collapse
|
37
|
Shah R, Nayyar M, Le FK, Labroo A, Nasr A, Rashid A, Davis DA, Weintraub WS, Boden WE. A meta-analysis of optimal medical therapy with or without percutaneous coronary intervention in patients with stable coronary artery disease. Coron Artery Dis 2022; 33:91-97. [PMID: 33878073 DOI: 10.1097/mca.0000000000001041] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
BACKGROUND Whether percutaneous coronary intervention (PCI) improves clinical outcomes in patients with chronic angina and stable coronary artery disease (CAD) has been a continuing area of investigation for more than two decades. The recently reported results of the International Study of Comparative Health Effectiveness with Medical and Invasive Approaches, the largest prospective trial of optimal medical therapy (OMT) with or without myocardial revascularization, provides a unique opportunity to determine whether there is an incremental benefit of revascularization in stable CAD patients. METHODS Scientific databases and websites were searched to find randomized clinical trials (RCTs). Pooled risk ratios were calculated using the random-effects model. RESULTS Data from 10 RCTs comprising 12 125 patients showed that PCI, when added to OMT, were not associated with lower all-cause mortality (risk ratios, 0.96; 95% CI, 0.87-1.08), cardiovascular mortality (risk ratios, 0.91; 95% CI, 0.79-1.05) or myocardial infarction (MI) (risk ratios, 0.90; 95% CI, 0.78-1.04) as compared with OMT alone. However, OMT+PCI was associated with improved anginal symptoms and a lower risk for revascularization (risk ratios, 0.52; 95% CI, 0.37-0.75). CONCLUSIONS In patient with chronic stable CAD (without left main disease or reduced ejection fraction), PCI in addition to OMT did not improve mortality or MI compared to OMT alone. However, this strategy is associated with a lower rate of revascularization and improved anginal symptoms.
Collapse
Affiliation(s)
- Rahman Shah
- Department of Medicine, University of Tennessee, Memphis, Tennessee
- Department of Cardiology, Gulf Coast Medical center, Alabama University of Osteopathic Medicine, Panama City, Florida
| | - Mannu Nayyar
- Department of Medicine, University of Tennessee, Memphis, Tennessee
| | - Francis K Le
- Department of Cardiology, Gulf Coast Medical center, Alabama University of Osteopathic Medicine, Panama City, Florida
| | - Ajay Labroo
- Department of Cardiology, Gulf Coast Medical center, Alabama University of Osteopathic Medicine, Panama City, Florida
| | - Abrar Nasr
- Department of Biology, University of Memphis, Memphis, Tennessee
| | - Abdul Rashid
- Department of Cardiology, University of Tennessee, Jackson, Tennessee
| | - Donnie A Davis
- Department of Cardiology, Gulf Coast Medical center, Alabama University of Osteopathic Medicine, Panama City, Florida
| | | | - William E Boden
- Department of Medicine, Veterans Affairs (VA) New England Healthcare System, Boston University
- Department of Medicine, Boston University School of Medicine, Boston, Massachusetts, USA
| |
Collapse
|
38
|
Nakamura M, Yaku H, Ako J, Arai H, Asai T, Chikamori T, Daida H, Doi K, Fukui T, Ito T, Kadota K, Kobayashi J, Komiya T, Kozuma K, Nakagawa Y, Nakao K, Niinami H, Ohno T, Ozaki Y, Sata M, Takanashi S, Takemura H, Ueno T, Yasuda S, Yokoyama H, Fujita T, Kasai T, Kohsaka S, Kubo T, Manabe S, Matsumoto N, Miyagawa S, Mizuno T, Motomura N, Numata S, Nakajima H, Oda H, Otake H, Otsuka F, Sasaki KI, Shimada K, Shimokawa T, Shinke T, Suzuki T, Takahashi M, Tanaka N, Tsuneyoshi H, Tojo T, Une D, Wakasa S, Yamaguchi K, Akasaka T, Hirayama A, Kimura K, Kimura T, Matsui Y, Miyazaki S, Okamura Y, Ono M, Shiomi H, Tanemoto K. JCS 2018 Guideline on Revascularization of Stable Coronary Artery Disease. Circ J 2022; 86:477-588. [DOI: 10.1253/circj.cj-20-1282] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Affiliation(s)
- Masato Nakamura
- Division of Cardiovascular Medicine, Toho University Ohashi Medical Center
| | - Hitoshi Yaku
- Department of Cardiovascular Surgery, Kyoto Prefectural University of Medicine
| | - Junya Ako
- Department of Cardiovascular Medicine, Kitasato University Graduate School of Medical Sciences
| | - Hirokuni Arai
- Department of Cardiovascular Surgery, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University
| | - Tohru Asai
- Department of Cardiovascular Surgery, Juntendo University Graduate School of Medicine
| | | | - Hiroyuki Daida
- Department of Cardiovascular Medicine, Juntendo University Graduate School of Medicine
| | - Kiyoshi Doi
- General and Cardiothoracic Surgery, Gifu University Graduate School of Medicine
| | - Toshihiro Fukui
- Department of Cardiovascular Surgery, Graduate School of Medical Sciences, Kumamoto University
| | - Toshiaki Ito
- Department of Cardiovascular Surgery, Japanese Red Cross Nagoya Daiichi Hospital
| | | | - Junjiro Kobayashi
- Department of Cardiovascular Surgery, National Cerebral and Cardiovascular Center
| | - Tatsuhiko Komiya
- Department of Cardiovascular Surgery, Kurashiki Central Hospital
| | - Ken Kozuma
- Department of Internal Medicine, Teikyo University Faculty of Medicine
| | - Yoshihisa Nakagawa
- Department of Cardiovascular Medicine, Shiga University of Medical Science
| | - Koichi Nakao
- Division of Cardiology, Saiseikai Kumamoto Hospital Cardiovascular Center
| | - Hiroshi Niinami
- Department of Cardiovascular Surgery, Tokyo Women’s Medical University
| | - Takayuki Ohno
- Department of Cardiovascular Surgery, Mitsui Memorial Hospital
| | - Yukio Ozaki
- Department of Cardiology, Fujita Health University Hospital
| | - Masataka Sata
- Department of Cardiovascular Medicine, Tokushima University Graduate School of Biomedical Sciences
| | | | - Hirofumi Takemura
- Department of Cardiovascular Surgery, Graduate School of Medical Sciences, Kanazawa University
| | | | - Satoshi Yasuda
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center
| | - Hitoshi Yokoyama
- Department of Cardiovascular Surgery, Fukushima Medical University
| | - Tomoyuki Fujita
- Department of Cardiovascular Surgery, National Cerebral and Cardiovascular Center
| | - Tokuo Kasai
- Department of Cardiology, Uonuma Institute of Community Medicine, Niigata University Uonuma Kikan Hospital
| | - Shun Kohsaka
- Department of Cardiology, Keio University School of Medicine
| | - Takashi Kubo
- Department of Cardiovascular Medicine, Wakayama Medical University
| | - Susumu Manabe
- Department of Cardiovascular Surgery, Tsuchiura Kyodo General Hospital
| | | | - Shigeru Miyagawa
- Frontier of Regenerative Medicine, Graduate School of Medicine, Osaka University
| | - Tomohiro Mizuno
- Department of Cardiovascular Surgery, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University
| | - Noboru Motomura
- Department of Cardiovascular Surgery, Graduate School of Medicine, Toho University
| | - Satoshi Numata
- Department of Cardiovascular Surgery, Kyoto Prefectural University of Medicine
| | - Hiroyuki Nakajima
- Department of Cardiovascular Surgery, Saitama Medical University International Medical Center
| | - Hirotaka Oda
- Department of Cardiology, Niigata City General Hospital
| | - Hiromasa Otake
- Department of Cardiovascular Medicine, Kobe University Graduate School of Medicine
| | - Fumiyuki Otsuka
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center
| | - Ken-ichiro Sasaki
- Division of Cardiovascular Medicine, Kurume University School of Medicine
| | - Kazunori Shimada
- Department of Cardiovascular Medicine, Juntendo University Graduate School of Medicine
| | - Tomoki Shimokawa
- Department of Cardiovascular Surgery, Sakakibara Heart Institute
| | - Toshiro Shinke
- Division of Cardiology, Department of Medicine, Showa University School of Medicine
| | - Tomoaki Suzuki
- Department of Cardiovascular Surgery, Shiga University of Medical Science
| | - Masao Takahashi
- Department of Cardiovascular Surgery, Hiratsuka Kyosai Hospital
| | - Nobuhiro Tanaka
- Department of Cardiology, Tokyo Medical University Hachioji Medical Center
| | | | - Taiki Tojo
- Department of Cardiovascular Medicine, Kitasato University Graduate School of Medical Sciences
| | - Dai Une
- Department of Cardiovascular Surgery, Okayama Medical Center
| | - Satoru Wakasa
- Department of Cardiovascular and Thoracic Surgery, Hokkaido University Graduate School of Medicine
| | - Koji Yamaguchi
- Department of Cardiovascular Medicine, Tokushima University Graduate School of Biomedical Sciences
| | - Takashi Akasaka
- Department of Cardiovascular Medicine, Wakayama Medical University
| | | | - Kazuo Kimura
- Cardiovascular Center, Yokohama City University Medical Center
| | - Takeshi Kimura
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University
| | - Yoshiro Matsui
- Department of Cardiovascular and Thoracic Surgery, Graduate School of Medicine, Hokkaido University
| | - Shunichi Miyazaki
- Division of Cardiology, Department of Internal Medicine, Faculty of Medicine, Kindai University
| | | | - Minoru Ono
- Department of Cardiac Surgery, Graduate School of Medicine, The University of Tokyo
| | - Hiroki Shiomi
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University
| | - Kazuo Tanemoto
- Department of Cardiovascular Surgery, Kawasaki Medical School
| | | |
Collapse
|
39
|
Tajabadi M, Goran Orimi H, Ramzgouyan MR, Nemati A, Deravi N, Beheshtizadeh N, Azami M. Regenerative strategies for the consequences of myocardial infarction: Chronological indication and upcoming visions. Biomed Pharmacother 2021; 146:112584. [PMID: 34968921 DOI: 10.1016/j.biopha.2021.112584] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2021] [Revised: 12/20/2021] [Accepted: 12/21/2021] [Indexed: 12/13/2022] Open
Abstract
Heart muscle injury and an elevated troponin level signify myocardial infarction (MI), which may result in defective and uncoordinated segments, reduced cardiac output, and ultimately, death. Physicians apply thrombolytic therapy, coronary artery bypass graft (CABG) surgery, or percutaneous coronary intervention (PCI) to recanalize and restore blood flow to the coronary arteries, albeit they were not convincingly able to solve the heart problems. Thus, researchers aim to introduce novel substitutional therapies for regenerating and functionalizing damaged cardiac tissue based on engineering concepts. Cell-based engineering approaches, utilizing biomaterials, gene, drug, growth factor delivery systems, and tissue engineering are the most leading studies in the field of heart regeneration. Also, understanding the primary cause of MI and thus selecting the most efficient treatment method can be enhanced by preparing microdevices so-called heart-on-a-chip. In this regard, microfluidic approaches can be used as diagnostic platforms or drug screening in cardiac disease treatment. Additionally, bioprinting technique with whole organ 3D printing of human heart with major vessels, cardiomyocytes and endothelial cells can be an ideal goal for cardiac tissue engineering and remarkable achievement in near future. Consequently, this review discusses the different aspects, advancements, and challenges of the mentioned methods with presenting the advantages and disadvantages, chronological indications, and application prospects of various novel therapeutic approaches.
Collapse
Affiliation(s)
- Maryam Tajabadi
- School of Metallurgy and Materials Engineering, Iran University of Science and Technology (IUST), Narmak, Tehran 16844, Iran
| | - Hanif Goran Orimi
- School of Metallurgy and Materials Engineering, Iran University of Science and Technology (IUST), Narmak, Tehran 16844, Iran; Regenerative Medicine Group (REMED), Universal Scientific Education and Research Network (USERN), Tehran, Iran
| | - Maryam Roya Ramzgouyan
- Department of Tissue Engineering, School of Advanced Technologies in Medicine, Tehran University of Medical Sciences, Iran; Regenerative Medicine Group (REMED), Universal Scientific Education and Research Network (USERN), Tehran, Iran
| | - Alireza Nemati
- Department of Biomedical Engineering, Amirkabir University of Technology (Tehran Polytechnic), Tehran, Iran; Regenerative Medicine Group (REMED), Universal Scientific Education and Research Network (USERN), Tehran, Iran
| | - Niloofar Deravi
- Student Research Committee, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran; Regenerative Medicine Group (REMED), Universal Scientific Education and Research Network (USERN), Tehran, Iran
| | - Nima Beheshtizadeh
- Department of Tissue Engineering, School of Advanced Technologies in Medicine, Tehran University of Medical Sciences, Iran; Regenerative Medicine Group (REMED), Universal Scientific Education and Research Network (USERN), Tehran, Iran
| | - Mahmoud Azami
- Department of Tissue Engineering, School of Advanced Technologies in Medicine, Tehran University of Medical Sciences, Iran; Regenerative Medicine Group (REMED), Universal Scientific Education and Research Network (USERN), Tehran, Iran.
| |
Collapse
|
40
|
Lawton JS, Tamis-Holland JE, Bangalore S, Bates ER, Beckie TM, Bischoff JM, Bittl JA, Cohen MG, DiMaio JM, Don CW, Fremes SE, Gaudino MF, Goldberger ZD, Grant MC, Jaswal JB, Kurlansky PA, Mehran R, Metkus TS, Nnacheta LC, Rao SV, Sellke FW, Sharma G, Yong CM, Zwischenberger BA. 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. Circulation 2021; 145:e18-e114. [PMID: 34882435 DOI: 10.1161/cir.0000000000001038] [Citation(s) in RCA: 136] [Impact Index Per Article: 45.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
AIM The guideline for coronary artery revascularization replaces the 2011 coronary artery bypass graft surgery and the 2011 and 2015 percutaneous coronary intervention guidelines, providing a patient-centric approach to guide clinicians in the treatment of patients with significant coronary artery disease undergoing coronary revascularization as well as the supporting documentation to encourage their use. METHODS A comprehensive literature search was conducted from May 2019 to September 2019, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Collaboration, CINHL Complete, and other relevant databases. Additional relevant studies, published through May 2021, were also considered. Structure: Coronary artery disease remains a leading cause of morbidity and mortality globally. Coronary revascularization is an important therapeutic option when managing patients with coronary artery disease. The 2021 coronary artery revascularization guideline provides recommendations based on contemporary evidence for the treatment of these patients. The recommendations present an evidence-based approach to managing patients with coronary artery disease who are being considered for coronary revascularization, with the intent to improve quality of care and align with patients' interests.
Collapse
|
41
|
Lawton JS, Tamis-Holland JE, Bangalore S, Bates ER, Beckie TM, Bischoff JM, Bittl JA, Cohen MG, DiMaio JM, Don CW, Fremes SE, Gaudino MF, Goldberger ZD, Grant MC, Jaswal JB, Kurlansky PA, Mehran R, Metkus TS, Nnacheta LC, Rao SV, Sellke FW, Sharma G, Yong CM, Zwischenberger BA. 2021 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization: Executive Summary: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation 2021; 145:e4-e17. [PMID: 34882436 DOI: 10.1161/cir.0000000000001039] [Citation(s) in RCA: 112] [Impact Index Per Article: 37.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
AIM The executive summary of the American College of Cardiology/American Heart Association/Society for Cardiovascular Angiography and Interventions coronary artery revascularization guideline provides the top 10 items readers should know about the guideline. In the full guideline, the recommendations replace the 2011 coronary artery bypass graft surgery guideline and the 2011 and 2015 percutaneous coronary intervention guidelines. This summary offers a patient-centric approach to guide clinicians in the treatment of patients with significant coronary artery disease undergoing coronary revascularization, as well as the supporting documentation to encourage their use. METHODS A comprehensive literature search was conducted from May 2019 to September 2019, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Collaboration, CINHL Complete, and other relevant databases. Additional relevant studies, published through May 2021, were also considered. Structure: Recommendations from the earlier percutaneous coronary intervention and coronary artery bypass graft surgery guidelines have been updated with new evidence to guide clinicians in caring for patients undergoing coronary revascularization. This summary includes recommendations, tables, and figures from the full guideline that relate to the top 10 take-home messages. The reader is referred to the full guideline for graphical flow charts, supportive text, and tables with additional details about the rationale for and implementation of each recommendation, and the evidence tables detailing the data considered in the development of this guideline.
Collapse
|
42
|
Lawton JS, Tamis-Holland JE, Bangalore S, Bates ER, Beckie TM, Bischoff JM, Bittl JA, Cohen MG, DiMaio JM, Don CW, Fremes SE, Gaudino MF, Goldberger ZD, Grant MC, Jaswal JB, Kurlansky PA, Mehran R, Metkus TS, Nnacheta LC, Rao SV, Sellke FW, Sharma G, Yong CM, Zwischenberger BA. 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. J Am Coll Cardiol 2021; 79:e21-e129. [PMID: 34895950 DOI: 10.1016/j.jacc.2021.09.006] [Citation(s) in RCA: 486] [Impact Index Per Article: 162.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
AIM The guideline for coronary artery revascularization replaces the 2011 coronary artery bypass graft surgery and the 2011 and 2015 percutaneous coronary intervention guidelines, providing a patient-centric approach to guide clinicians in the treatment of patients with significant coronary artery disease undergoing coronary revascularization as well as the supporting documentation to encourage their use. METHODS A comprehensive literature search was conducted from May 2019 to September 2019, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Collaboration, CINHL Complete, and other relevant databases. Additional relevant studies, published through May 2021, were also considered. STRUCTURE Coronary artery disease remains a leading cause of morbidity and mortality globally. Coronary revascularization is an important therapeutic option when managing patients with coronary artery disease. The 2021 coronary artery revascularization guideline provides recommendations based on contemporary evidence for the treatment of these patients. The recommendations present an evidence-based approach to managing patients with coronary artery disease who are being considered for coronary revascularization, with the intent to improve quality of care and align with patients' interests.
Collapse
|
43
|
2021 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization: Executive Summary: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. J Am Coll Cardiol 2021; 79:197-215. [PMID: 34895951 DOI: 10.1016/j.jacc.2021.09.005] [Citation(s) in RCA: 142] [Impact Index Per Article: 47.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
AIM The executive summary of the American College of Cardiology/American Heart Association/Society for Cardiovascular Angiography and Interventions coronary artery revascularization guideline provides the top 10 items readers should know about the guideline. In the full guideline, the recommendations replace the 2011 coronary artery bypass graft surgery guideline and the 2011 and 2015 percutaneous coronary intervention guidelines. This summary offers a patient-centric approach to guide clinicians in the treatment of patients with significant coronary artery disease undergoing coronary revascularization, as well as the supporting documentation to encourage their use. METHODS A comprehensive literature search was conducted from May 2019 to September 2019, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Collaboration, CINHL Complete, and other relevant databases. Additional relevant studies, published through May 2021, were also considered. STRUCTURE Recommendations from the earlier percutaneous coronary intervention and coronary artery bypass graft surgery guidelines have been updated with new evidence to guide clinicians in caring for patients undergoing coronary revascularization. This summary includes recommendations, tables, and figures from the full guideline that relate to the top 10 take-home messages. The reader is referred to the full guideline for graphical flow charts, supportive text, and tables with additional details about the rationale for and implementation of each recommendation, and the evidence tables detailing the data considered in the development of this guideline.
Collapse
|
44
|
Santucci A, Cavallini C. The ISCHEMIA trial: optimal medical therapy against PTCA in the stable patient: the endless story. Eur Heart J Suppl 2021; 23:E55-E58. [PMID: 34650355 PMCID: PMC8503493 DOI: 10.1093/eurheartj/suab088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
In patients with acute coronary syndrome, an aggressive approach with coronary angiography and revascularization leads to important benefits compared to medical therapy alone. On the contrary, the prognostic impact of coronary revascularization in patients suffering from stable coronary artery disease has long been the subject of debate. The pivotal study in this area is COURAGE, published in 2007, in which coronary revascularization showed no benefit about the combined endpoint of death from all causes and acute myocardial infarction (AMI), compared to medical therapy. The ISCHEMIA study, published in 2020, compared selective coronary angiography and revascularization vs. a non-invasive approach. By protocol, the patients were initially evaluated with coronary computed axial tomography angiography: in case of coronary stenosis >50%, they were then randomized to the two strategies. While in the invasive arm patients were revascularized, in the non-invasive arm revascularization was used only in case of patient destabilization. As in COURAGE, the results of ISCHEMIA did not demonstrate superiority of revascularization over medical therapy alone for a combined endpoint of cardiovascular death, AMI, or hospitalization for unstable angina, heart failure, or cardiac arrest. Based on recent evidence from ISCHEMIA, it is therefore confirmed that coronary revascularization in stable patients does not seem to improve the prognosis compared to medical therapy alone.
Collapse
Affiliation(s)
- Andrea Santucci
- Azienda Ospedaliera S.Maria della Misericordia, Piazzale Menghini 1, 06129 Perugia, Italy
| | - Claudio Cavallini
- Azienda Ospedaliera S.Maria della Misericordia, Piazzale Menghini 1, 06129 Perugia, Italy
| |
Collapse
|
45
|
Winther S, Andersen IT, Gormsen LC, Steffensen FH, Nielsen LH, Grove EL, Diederichsen ACP, Urbonaviciene G, Lambrechtsen J, Zaremba T, Elpert FP, Husain M, Zelechowski MW, Bøtker HE, Bøttcher M. Prognostic value of myocardial perfusion imaging after first-line coronary computed tomography angiography: A multi-center cohort study. J Cardiovasc Comput Tomogr 2021; 16:34-40. [PMID: 34475016 DOI: 10.1016/j.jcct.2021.08.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Revised: 07/27/2021] [Accepted: 08/16/2021] [Indexed: 11/30/2022]
Abstract
PURPOSE Further diagnostic testing may be required after a coronary computed tomography angiography (CTA) showing suspected coronary stenosis. Whether myocardial perfusion imaging (MPI) provides further prognostic information post-CTA remains debated. We evaluated the prognosis for patients completing CTA stratified for post-CTA diagnostic work-up using real-world data. METHODS We identified all patients in our uptake area with angina symptoms undergoing first-time CTA over a 10-year period. Follow-up time was a median of 3.7 years [1.9-5.8]. The primary endpoint was a composite of myocardial infarction or death. The secondary endpoint was late revascularization. RESULTS During the study period 53,351 patients underwent CTA. Of these, 24% were referred for further down-stream testing, 3,547 (7%) to MPI and 9,135 (17%) to invasive coronary angiography (ICA). The primary and secondary endpoints occurred in 2,026 (3.8%) and 954 (1.8%) patients. Patient-characteristic-adjusted hazard ratios for the primary and secondary endpoint using patients with a normal CTA as reference were 1.37 (1.21-1.55) and 2.50 (1.93-3.23) for patient treated medically, 1.68 (1.39-2.03) and 6.13 (4.58-8.21) for patients referred to MPI and 1.94 (1.69-2.23) and 9.18 (7.16-11.78) for patients referred for ICA, respectively. Adjusted analysis with stratification for disease severity at CTA showed similar hazard ratios for patients treated medically after CTA and patients referred for MPI and treated medically after the MPI. CONCLUSION In patients completing coronary CTA, second-line MPI testing seems to identify patients at low risk of future events. MPI seems to have the potential to act as gatekeeper for ICA after coronary CTA.
Collapse
Affiliation(s)
- Simon Winther
- Department of Cardiology, Hospital Unit West, Herning, Denmark; Department of Clinical Medicine, Faculty of Health, Aarhus University, Aarhus, Denmark.
| | | | | | | | | | - Erik Lerkevang Grove
- Department of Clinical Medicine, Faculty of Health, Aarhus University, Aarhus, Denmark; Department of Cardiology, Aarhus University Hospital, Denmark.
| | | | | | - Jess Lambrechtsen
- Department of Cardiology, Odense University Hospital, Svendborg, Denmark.
| | - Tomas Zaremba
- Department of Cardiology, Aalborg University Hospital, Aalborg, Denmark.
| | - Frank-Peter Elpert
- Department of Cardiology, Regional Hospital of South Jutland, Aabenraa, Denmark.
| | - Majed Husain
- Department of Cardiology, Regional Hospital of South West Denmark, Esbjerg, Denmark.
| | | | - Hans Erik Bøtker
- Department of Clinical Medicine, Faculty of Health, Aarhus University, Aarhus, Denmark; Department of Cardiology, Aarhus University Hospital, Denmark.
| | - Morten Bøttcher
- Department of Cardiology, Hospital Unit West, Herning, Denmark; Department of Clinical Medicine, Faculty of Health, Aarhus University, Aarhus, Denmark.
| | | |
Collapse
|
46
|
Impact of Optimal Medical Therapy on 10-Year Mortality After Coronary Revascularization. J Am Coll Cardiol 2021; 78:27-38. [PMID: 34210411 DOI: 10.1016/j.jacc.2021.04.087] [Citation(s) in RCA: 36] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Revised: 04/12/2021] [Accepted: 04/23/2021] [Indexed: 11/19/2022]
Abstract
BACKGROUND The benefit of optimal medical therapy (OMT) on 5-year outcomes in patients with 3-vessel disease and/or left main disease after percutaneous coronary intervention or coronary artery bypass grafting (CABG) was demonstrated in the randomized SYNTAX (Synergy Between PCI With Taxus and Cardiac Surgery) trial. OBJECTIVES The objective of this analysis is to assess the impact of the status of OMT at 5 years on 10-year mortality after percutaneous coronary intervention or CABG. METHODS This is a subanalysis of the SYNTAXES (Synergy Between PCI With Taxus and Cardiac Surgery Extended Survival) study, which evaluated for up to 10 years the vital status of patients who were originally enrolled in the SYNTAX trial. OMT was defined as the combination of 4 types of medications: at least 1 antiplatelet drug, statin, angiotensin-converting enzyme inhibitor/angiotensin receptor blocker, and beta-blocker. After stratifying participants by the number of individual OMT agents at 5 years and randomized treatment, a landmark analysis was conducted to assess the association between treatment response and 10-year mortality. RESULTS In 1,472 patients, patients on OMT at 5 years had a significantly lower mortality at 10 years compared with those on ≤2 types of medications (13.1% vs 19.9%; adjusted HR: 0.470; 95% CI: 0.292-0.757; P = 0.002) but had a mortality similar to those on 3 types of medications. Furthermore, patients undergoing CABG with the individual OMT agents, antiplatelet drug and statin, at 5 years had lower 10-year mortality than those without. CONCLUSIONS In patients with 3-vessel and/or left main disease undergoing percutaneous coronary intervention or CABG, medication status at 5 years had a significant impact on 10-year mortality. Patients on OMT with guideline-recommended pharmacologic therapy at 5 years had a survival benefit. (Synergy Between PCI With Taxus and Cardiac Surgery: SYNTAX Extended Survival [SYNTAXES]; NCT03417050; Taxus Drug-Eluting Stent Versus Coronary Artery Bypass Surgery for the Treatment of Narrowed Arteries [SYNTAX]; NCT00114972).
Collapse
|
47
|
Boden WE, Gersh BJ. Defining the Proper SYNTAX for Long-Term Benefit of Myocardial Revascularization With Optimal Medical Therapy. J Am Coll Cardiol 2021; 78:39-41. [PMID: 34210412 DOI: 10.1016/j.jacc.2021.04.088] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2021] [Accepted: 04/26/2021] [Indexed: 10/21/2022]
Affiliation(s)
- William E Boden
- VA New England Health Care System, Massachusetts Veterans Epidemiology, Research, and Informatics Center, Boston University School of Medicine, Boston, Massachusetts, USA.
| | - Bernard J Gersh
- Department of Cardiovascular Medicine, Mayo Clinic College of Medicine and Science, Rochester, Minnesota, USA
| |
Collapse
|
48
|
Sharir T, Hollander I, Hemo B, Tsamir J, Yefremov N, Bojko A, Prokhorov V, Pinskiy M, Slomka P, Amos K. Survival benefit of coronary revascularization after myocardial perfusion SPECT: The role of ischemia. J Nucl Cardiol 2021; 28:1676-1687. [PMID: 31823328 DOI: 10.1007/s12350-019-01932-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2019] [Accepted: 10/04/2019] [Indexed: 10/25/2022]
Abstract
BACKGROUND Survival benefit of revascularization over medical therapy (MT) in patients with stable ischemic heart disease (SIHD) is uncertain. We evaluated the prognostic effects of revascularization in patients with SIHD undergoing single-photon emission computed tomography myocardial perfusion imaging (SPECT-MPI). METHODS Of 47,894 patients, 7973 had ischemia ≥ 5% of the left ventricle. Of these, 1837 underwent early revascularization (≤ 60 days after SPECT-MPI). The rest were MT subgroup. Follow-up period was 4.04 ± 1.86 years. Statin therapy intensity and adherence were assessed. Outcomes were all-cause mortality, death + non-fatal myocardial infarction (MI), and MACE [major adverse cardiac event = death + MI + late revascularization (> 60 days after SPECT-MPI)]. RESULTS Among patients with moderate-severe ischemia (≥ 10%), death rate was lower in early revascularization compared to MT subgroup (1.42%/year vs 3.12%/year, adjusted hazard ratio (HR) 0.67 (95% CI 0.50-0.90, P = .008). Death + MI and MACE rates were also lower, adjusted HR 0.69 (0.55-0.88, P = .003) and 0.80 (0.69-0.92, P = .003). Revascularization was beneficial in optimal statin therapy subgroup (death rate 1.04%/year vs 2.36%/year, adjusted HR 0.51 (0.30-0.86, P = .012). In mild ischemia (5%-9%), revascularization did not improve survival or MI-free survival, and was associated with higher MACE rate (8.86%/year vs 7.67%/year, adjusted HR 1.30 (1.12-1.52, P < .001). CONCLUSION Compared to MT, revascularization was associated with reduced risk of death, death + MI, and MACE in patients with moderate-severe ischemia, incremental over optimal statin therapy. In mild ischemia, revascularization was associated with higher risk of MACE, driven by late revascularization, with no impact on death and death + MI.
Collapse
Affiliation(s)
- Tali Sharir
- Department of Nuclear Cardiology, Assuta Medical Centers, 96 Igal Alon, Building C, 67891, Tel Aviv, Israel.
- Faculty of Health Sciences, Ben Gurion University of the Negev, Beer Sheva, Israel.
| | - Idan Hollander
- Department of Nuclear Cardiology, Assuta Medical Centers, 96 Igal Alon, Building C, 67891, Tel Aviv, Israel
| | | | | | - Nikolay Yefremov
- Department of Nuclear Cardiology, Assuta Medical Centers, 96 Igal Alon, Building C, 67891, Tel Aviv, Israel
| | - Andrzej Bojko
- Department of Nuclear Cardiology, Assuta Medical Centers, 96 Igal Alon, Building C, 67891, Tel Aviv, Israel
| | - Vitaly Prokhorov
- Department of Nuclear Cardiology, Assuta Medical Centers, 96 Igal Alon, Building C, 67891, Tel Aviv, Israel
| | - Marina Pinskiy
- Department of Nuclear Cardiology, Assuta Medical Centers, 96 Igal Alon, Building C, 67891, Tel Aviv, Israel
| | - Piotr Slomka
- Cedars Sinai Medical Center, Los Angeles, CA, USA
| | - Katz Amos
- Faculty of Health Sciences, Ben Gurion University of the Negev, Beer Sheva, Israel
| |
Collapse
|
49
|
Mesnier J, Ducrocq G, Danchin N, Ferrari R, Ford I, Tardif JC, Tendera M, Fox KM, Steg PG. International Observational Analysis of Evolution and Outcomes of Chronic Stable Angina: The Multinational CLARIFY Study. Circulation 2021; 144:512-523. [PMID: 34261331 PMCID: PMC8360663 DOI: 10.1161/circulationaha.121.054567] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Supplemental Digital Content is available in the text. Background: Although angina is common in patients with stable coronary artery disease, limited data are available on its prevalence, natural evolution, and outcomes in the era of effective cardiovascular drugs and widespread use of coronary revascularization. Methods: Using data from 32 691 patients with stable coronary artery disease from the prospective observational CLARIFY registry (Prospective Observational Longitudinal Registry of Patients with Stable Coronary Artery Disease), anginal status was mapped each year in patients without new coronary revascularization or new myocardial infarction. The use of medical interventions in the year preceding angina resolution was explored. The effect of 1-year changes in angina status on 5-year outcomes was analyzed using multivariable analysis. Results: Among 7212 (22.1%) patients who reported angina at baseline, angina disappeared (without coronary revascularization) in 39.6% at 1 year, with further annual decreases. In patients without angina at baseline, 2.0% to 4.8% developed angina each year. During 5-year follow-up, angina was controlled in 7773 patients, in whom resolution of angina was obtained with increased use of antianginal treatment in 11.1%, with coronary revascularization in 4.5%, and without any changes in medication or revascularization in 84.4%. Compared to patients without angina at baseline and 1 year, persistence of angina and occurrence of angina at 1 year with conservative management were each independently associated with higher rates of cardiovascular death or myocardial infarction (adjusted hazard ratio, 1.32 [95% CI, 1.12−1.55] for persistence of angina; adjusted hazard ratio, 1.37 [95% CI, 1.11−1.70] for occurrence of angina) at 5 years. Patients whose angina had resolved at 1 year with conservative management were not at higher risk of cardiovascular death or myocardial infarction than those who never experienced angina (adjusted hazard ratio, 0.97 [95% CI, 0.82−1.15]). Conclusions: Angina affects almost one-quarter of patients with stable coronary artery disease but resolves without events or coronary revascularization in most patients. Resolution of angina within 1 year with conservative management predicted outcomes similar to lack of angina, whereas persistence or occurrence was associated with worse outcomes. Because most patients with angina are likely to experience resolution of symptoms, and because there is no demonstrated outcome benefit to routine revascularization, this study emphasizes the value of conservative management of stable coronary artery disease. Registration: URL: https://www.isrctn.com; Unique identifier: ISRCTN43070564.
Collapse
Affiliation(s)
- Jules Mesnier
- Assistance Publique-Hôpitaux de Paris, Hôpital Bichat, France (J.M., G.D., P.G.S.).,French Alliance for Cardiovascular Trials, Paris (J.M., G.D., P.G.S.)
| | - Gregory Ducrocq
- Assistance Publique-Hôpitaux de Paris, Hôpital Bichat, France (J.M., G.D., P.G.S.).,French Alliance for Cardiovascular Trials, Paris (J.M., G.D., P.G.S.).,Institut national de la santé et de la recherche médicale U1148, Paris, France (G.D., P.G.S.).,Université de Paris, France (G.D., N.D., P.G.S.)
| | - Nicolas Danchin
- Université de Paris, France (G.D., N.D., P.G.S.).,Assistance Publique-Hôpitaux de Paris, Hôpital Européen Georges Pompidou, France (N.D.)
| | - Roberto Ferrari
- Maria Cecilia Hospital, Gruppo Villa Maria Care & Research, Cotignola (Ravenna), Italy (R.F.).,Centro Cardiologico Universitario di Ferrara, University of Ferrara, Italy (R.F.)
| | - Ian Ford
- Robertson Centre for Biostatistics, Glasgow, United Kingdom (I.F.)
| | | | - Michal Tendera
- School of Medicine in Katowice, Medical University of Silesia, Poland (M.T.)
| | - Kim M Fox
- Imperial College, Royal Brompton Hospital, London, United Kingdom (K.M.F., P.G.S.)
| | - Philippe Gabriel Steg
- Assistance Publique-Hôpitaux de Paris, Hôpital Bichat, France (J.M., G.D., P.G.S.).,French Alliance for Cardiovascular Trials, Paris (J.M., G.D., P.G.S.).,Institut national de la santé et de la recherche médicale U1148, Paris, France (G.D., P.G.S.).,Université de Paris, France (G.D., N.D., P.G.S.).,Imperial College, Royal Brompton Hospital, London, United Kingdom (K.M.F., P.G.S.)
| | | |
Collapse
|
50
|
Implications of the ISCHEMIA trial on the practice of surgical myocardial revascularization. J Thorac Cardiovasc Surg 2021; 162:90-99. [DOI: 10.1016/j.jtcvs.2020.07.123] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Revised: 07/16/2020] [Accepted: 07/17/2020] [Indexed: 01/09/2023]
|