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Vrints C, Andreotti F, Koskinas KC, Rossello X, Adamo M, Ainslie J, Banning AP, Budaj A, Buechel RR, Chiariello GA, Chieffo A, Christodorescu RM, Deaton C, Doenst T, Jones HW, Kunadian V, Mehilli J, Milojevic M, Piek JJ, Pugliese F, Rubboli A, Semb AG, Senior R, Ten Berg JM, Van Belle E, Van Craenenbroeck EM, Vidal-Perez R, Winther S. 2024 ESC Guidelines for the management of chronic coronary syndromes. Eur Heart J 2024:ehae177. [PMID: 39210710 DOI: 10.1093/eurheartj/ehae177] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/04/2024] Open
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Florek K, Kübler M, Górka M, Kübler P. New Modifiable Risk Factors Influencing Coronary Artery Disease Severity. Int J Mol Sci 2024; 25:7766. [PMID: 39063008 PMCID: PMC11276953 DOI: 10.3390/ijms25147766] [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: 05/22/2024] [Revised: 07/03/2024] [Accepted: 07/07/2024] [Indexed: 07/28/2024] Open
Abstract
Cardiovascular diseases (CVDs) remain the leading cause of death worldwide with coronary artery disease (CAD) being the first culprit in this group. In terms of CAD, not only its presence but also its severity plays a role in the patient's treatment and prognosis. CAD complexity can be assessed with the indicator named the SYNTAX score (SS). A higher SS is associated with major adverse cardiovascular event (MACE) occurrence in short- and long-term observations. Hence, the risk factors affecting CAD severity based on SS results may help lower the risk among patients with already developed CAD to reduce their impact on coronary atherosclerosis progression. The well-established risk factors of CAD are consistent with those associated with the coronary plaque burden. However, recently, it was shown that new indicators exist, which we present in this paper, that significantly contribute to CAD complexity such as inflammatory parameters, C-reactive protein (CRP), ratios based on blood smear results, and uric acid. Moreover, microbiota alteration, vitamin D deficiency, and obstructive sleep apnea (OSA) also predicted CAD severity. However, sometimes, certain indicators were revealed as significant only in terms of chronic coronary syndromes (CCSs) or specific acute coronary syndromes (ACSs). Importantly, there is a need to apply the interdisciplinary and translational approach to the novel CAD severity risk assessment to maximize the impact of secondary prevention among patients at risk of coronary atherosclerosis progression.
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Affiliation(s)
- Kamila Florek
- Student Scientific Group of Invasive Cardiology, Institute of Heart Diseases, Wroclaw Medical University, 50-369 Wroclaw, Poland
| | - Maja Kübler
- Student Scientific Group of Invasive Cardiology, Institute of Heart Diseases, Wroclaw Medical University, 50-369 Wroclaw, Poland
| | - Magdalena Górka
- Student Scientific Group of Invasive Cardiology, Institute of Heart Diseases, Wroclaw Medical University, 50-369 Wroclaw, Poland
| | - Piotr Kübler
- Institute of Heart Diseases, University Hospital, 50-556 Wroclaw, Poland
- Department of Cardiology, Faculty of Medicine, Institute of Heart Diseases, Wroclaw Medical University, 50-367 Wroclaw, Poland
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Marengo G, Bruno F, Scudeler L, Savoca F, Zugna D, Isaevska E, Pilgrim T, Jensen LO, De Filippo O, Richiardi L, De Ferrari GM, D'Ascenzo F. Comparison Among Ultra-Thin Coronary Stents: A Network Meta-Analysis. Am J Cardiol 2024; 216:9-18. [PMID: 38301755 DOI: 10.1016/j.amjcard.2024.01.018] [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: 10/09/2023] [Revised: 01/08/2024] [Accepted: 01/19/2024] [Indexed: 02/03/2024]
Abstract
Ultrathin-strut drug-eluting stents (DES) have been related to potential improvement in stent-related outcomes compared with thicker-struts DES. However, comparisons among different ultrathin devices are lacking. All randomized controlled trials comparing ultrathin (struts thickness <70 µm) and thicker-struts DESs in an all-comers population were included. Target lesion failure (TLF), as defined by included trials, at 1-year follow-up was the primary end point. Overall mortality, myocardial infarction, target lesion revascularization (TLR), and stent thrombosis were the secondary end points. Arms of included trials were compared using network meta-analysis. Nine studies encompassing 20,081 patients were included, of which 9,509 patients had an ultrathin DES: Orsiro (evaluated in 7 arms with 8,086 patients), MiStent (1 arm with 703 patients), or Supraflex (1 arm with 720 patients). At 1-year follow-up, no significant differences were noted for TLF among these ultrathin DES. In particular, Orsiro was associated with a similar risk of TLF compared with Supraflex (risk rate 1.07, 95% confidence interval 0.59 to 1.78) and showed the highest probability of performing best in terms of TLF, myocardial infarction, and TLR. Ultrathin DES are all associated with a comparable risk of TLF compared with thicker-strut DES. In terms of TLR and TLF risk, Orsiro was the one with the highest probability of best performances, either compared with other ultrathin DES or to devices with thicker struts.
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Affiliation(s)
- Giorgio Marengo
- Division of Cardiology, Cardiovascular and Thoracic Department, Città della Salute e della Scienza, University of Turin, Italy
| | - Francesco Bruno
- Division of Cardiology, Cardiovascular and Thoracic Department, Città della Salute e della Scienza, University of Turin, Italy
| | - Luca Scudeler
- Division of Cardiology, Cardiovascular and Thoracic Department, Città della Salute e della Scienza, University of Turin, Italy
| | - Federica Savoca
- Division of Cardiology, Cardiovascular and Thoracic Department, Città della Salute e della Scienza, University of Turin, Italy
| | - Daniela Zugna
- Cancer Epidemiology Unit, Department of Medical Sciences, University of Turin, Italy
| | - Elena Isaevska
- Cancer Epidemiology Unit, Department of Medical Sciences, University of Turin, Italy
| | - Thomas Pilgrim
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | | | - Ovidio De Filippo
- Division of Cardiology, Cardiovascular and Thoracic Department, Città della Salute e della Scienza, University of Turin, Italy.
| | - Lorenzo Richiardi
- Cancer Epidemiology Unit, Department of Medical Sciences, University of Turin, Italy
| | - Gaetano Maria De Ferrari
- Division of Cardiology, Cardiovascular and Thoracic Department, Città della Salute e della Scienza, University of Turin, Italy
| | - Fabrizio D'Ascenzo
- Division of Cardiology, Cardiovascular and Thoracic Department, Città della Salute e della Scienza, University of Turin, Italy
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Khawaja M, Britt M, Khan MA, Munaf U, Arshad H, Siddiqui R, Virk HUH, Alam M, Krittanawong C. Left Main Coronary Artery Disease: A Contemporary Review of Diagnosis and Management. Rev Cardiovasc Med 2024; 25:66. [PMID: 39077332 PMCID: PMC11263144 DOI: 10.31083/j.rcm2502066] [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: 11/02/2023] [Revised: 12/10/2023] [Accepted: 12/29/2023] [Indexed: 07/31/2024] Open
Abstract
Significant left main coronary artery disease is a very high-risk subgroup of coronary artery disease that is a crucial indicator of heightened morbidity and mortality rates. Despite its clinical significance, uncertainties persist regarding the optimal management strategy for patients, particularly given its phenotypic variations. Existing evidence-based guidelines offer insights into revascularization options, yet questions remain regarding long-term prognoses and clinical outcomes when comparing percutaneous coronary intervention to coronary artery bypass grafting. This comprehensive review aims to provide an in-depth analysis of contemporary strategies for the diagnosis, assessment, and treatment of left main coronary artery disease. By synthesizing current literature and addressing the evolving landscape of revascularization modalities, this review seeks to contribute valuable insights for clinicians and researchers grappling with the complexities of managing left main coronary artery disease.
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Affiliation(s)
- Muzamil Khawaja
- Department of Cardiology, Emory University, Atlanta, GA 30322, USA
| | - Michael Britt
- Department of Internal Medicine, Emory University, Atlanta, GA 30322, USA
| | - Muhammad Asad Khan
- Department of Family Medicine, West Chicago Immediate Care, West Chicago, IL 60185-2847, USA
| | - Uzair Munaf
- Department of Internal Medicine, Dow Medical College, 75300 Karachi, Pakistan
| | - Hassaan Arshad
- Department of Internal Medicine, Capital Health Regional Medical Centre, Trenton, NJ 08638-4143, USA
| | - Rehma Siddiqui
- Department of Internal Medicine, The University of Mississippi Medical Center, Jackson, MS 39216, USA
| | - Hafeez Ul Hassan Virk
- Harrington Heart & Vascular Institute, Case Western Reserve University, University Hospitals Cleveland Medical Center, Cleveland, OH 44106-2333, USA
| | - Mahboob Alam
- Department of Cardiology, The Texas Heart Institute, Baylor College of Medicine, Houston, TX 77030, USA
| | - Chayakrit Krittanawong
- Cardiology Division, NYU Langone Health and NYU School of Medicine, New York, NY 10016, USA
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Bruno F, Kang J, Elia E, Han JK, De Filippo O, Yang HM, Gallone G, Park KW, De Luca L, Kang HJ, Quadri G, Gwon HC, Chun WJ, Giannino G, Hur SH, Han SH, Truffa A, Bin Song Y, Cortese B, Choi KH, Chieffo A, Hong SJ, Di Pietro G, Doh JH, Wanha W, Nam CW, Kim HS, Mattesini A, de De Ferrari GM, Koo BK, D'Ascenzo F. Impact of diabetes on long-term outcomes of bifurcation percutaneous coronary intervention. An analysis from the BIFURCAT registry. Catheter Cardiovasc Interv 2023; 102:620-630. [PMID: 37668085 DOI: 10.1002/ccd.30802] [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: 08/23/2022] [Revised: 06/29/2023] [Accepted: 07/28/2023] [Indexed: 09/06/2023]
Abstract
BACKGROUND It is still unclear the impact of diabetes mellitus (DM) in complex coronary lesions treated with percutaneous coronary intervention (PCI) which themselves are at increased incidence of adverse events. METHODS BIFURCAT registry encompassed patients treated with PCI for coronary bifurcation lesion from the COBIS III and the RAIN registry. The primary endpoint was the occurrence of major cardiovascular adverse event (MACE), a composite and mutual exclusive of all-cause death or myocardial infarction (MI) or target-lesion revascularization (TLR). A total of 5537 patients were included in the analysis and 1834 (33%) suffered from DM. RESULTS After a median follow-up of 21 months, diabetic patients had a higher incidence of MACE (17% vs. 9%, p < 0.001), all-cause mortality (9% vs. 4%, p < 0.001), TLR (5% vs. 3%, p = 0.001), MI (4% vs. 2%, p < 0.001), and stent thrombosis (ST) (2% vs. 1%, p = 0.007). After multivariate analysis, diabetes remained significantly associated with MACE (hazard ratio [HR]: 1.37; confidence interval [CI]: 1.13-1.65; p = 0.001), all-cause death (HR: 1.65; 95% CI: 1.24-2.19, p = 0.001), TLR (HR: 1.45; CI: 1.03-2.04; p = 0.031) and ST (HR: 1.73, CI: 1.04-2.88; p = 0.036), but not with MI (HR: 1.34; CI: 0.93-1.92; p = 0.11). Among diabetics, chronic kidney disease (HR: 2.99; CI: 2.21-4.04), baseline left ventricular ejection fraction (HR: 0.98; CI: 0.97-0.99), femoral access (HR: 1.62; CI: 1.23-2.15), left main coronary artery (HR: 1.44; CI: 1.06-1.94), main branch diameter (HR: 0.79; CI: 0.66-0.94) and final kissing balloon (HR: 0.70; CI: 0.52-0.93) were independent predictors of MACE at follow-up. CONCLUSIONS Patients with DM treated with PCI for coronary bifurcations have a worse prognosis due to higher incidence of MACE, all-cause mortality, TLR and ST compared to the non-diabetics.
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Affiliation(s)
- Francesco Bruno
- Division of Cardiology, Department of Medical Sciences, University of Turin, Turin, Italy
| | - Jeehoon Kang
- Department of Internal Medicine and Cardiovascular Center, Seoul National University Hospital, Seoul, South Korea
| | - Edoardo Elia
- Division of Cardiology, Department of Medical Sciences, University of Turin, Turin, Italy
| | - Jung-Kyu Han
- Department of Internal Medicine and Cardiovascular Center, Seoul National University Hospital, Seoul, South Korea
| | - Ovidio De Filippo
- Division of Cardiology, Department of Medical Sciences, University of Turin, Turin, Italy
| | - Han-Mo Yang
- Department of Internal Medicine and Cardiovascular Center, Seoul National University Hospital, Seoul, South Korea
| | - Guglielmo Gallone
- Division of Cardiology, Department of Medical Sciences, University of Turin, Turin, Italy
| | - Kyung-Woo Park
- Department of Internal Medicine and Cardiovascular Center, Seoul National University Hospital, Seoul, South Korea
| | - Leonardo De Luca
- Department of Cardiosciences, San Camillo-Forlanini Hospital, Roma, Italy
| | - Hyun-Jae Kang
- Department of Internal Medicine and Cardiovascular Center, Seoul National University Hospital, Seoul, South Korea
| | - Giorgio Quadri
- Division of Cardiology, Ospedale di Rivoli, Rivoli, Italy
| | - Hyeon-Cheol Gwon
- Department of Cardiology, Sungkyunkwan University Samsung Medical Center, Seoul, South Korea
| | - Woo Jung Chun
- Department of Internal Medicine, Samsung Changwon Hospital, Changwon, South Korea
| | - Giuseppe Giannino
- Division of Cardiology, Department of Medical Sciences, University of Turin, Turin, Italy
| | - Seung-Ho Hur
- Department of Internal Medicine, Keimyung University Dongsan Medical Center, Daegu, South Korea
| | - Seung Hwan Han
- Department of Internal Medicine, Gachon University Gil Hospital, Incheon, South Korea
| | | | - Young Bin Song
- Department of Cardiology, Sungkyunkwan University Samsung Medical Center, Seoul, South Korea
| | - Bernardo Cortese
- Division of cardiology, Cardiovascular Research Center, Fondazione Ricerca e Innovazione Cardiovascolare, Milan, Italy
| | - Ki Hong Choi
- Department of Internal Medicine, Samsung Changwon Hospital, Changwon, South Korea
| | - Alaide Chieffo
- Division of Cardiology, Ospedale San Raffaele, Milan, Italy
| | - Soon-Jun Hong
- Department of Cardiology, Cardiovascular Center, Korea University Anam Hospital, Seoul, South Korea
| | - Gianluca Di Pietro
- Division of Cardiology, Department of Medical Sciences, University of Turin, Turin, Italy
| | - Joon-Hyung Doh
- Department of Internal Medicine, Inje University Ilsan Paik Hospital, Goyang, South Korea
| | - Wojciech Wanha
- Department of Cardiology, Medical University of Silesia, Katowice, Poland
| | - Chang-Wook Nam
- Department of Internal Medicine, Keimyung University Dongsan Medical Center, Daegu, South Korea
| | - Hyo-Soo Kim
- Department of Internal Medicine and Cardiovascular Center, Seoul National University Hospital, Seoul, South Korea
| | | | | | - Bon-Kwon Koo
- Department of Internal Medicine and Cardiovascular Center, Seoul National University Hospital, Seoul, South Korea
| | - Fabrizio D'Ascenzo
- Division of Cardiology, Department of Medical Sciences, University of Turin, Turin, Italy
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Dumitrascu S, Bartos D, Ungureanu C. Outcomes after Percutaneous Coronary Intervention in Patients with Extremely Calcified Left Main Lesions. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:medicina59050825. [PMID: 37241057 DOI: 10.3390/medicina59050825] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/26/2023] [Revised: 04/18/2023] [Accepted: 04/21/2023] [Indexed: 05/28/2023]
Abstract
Background and Objectives: Available data with regard to the outcomes of patients with severely calcified left main (LM) lesions after revascularization by percutaneous coronary intervention (PCI) when compared to non-calcified LM lesions is unclear. Materials and Methods: The present study sought to retrospectively investigate in hospital and 1 year post-intervention outcomes of patients with extremely calcified LM lesions after PCI facilitated by calcium-dedicated devices (CdD). Seventy consecutive patients with LM PCI were included. CdD requirement was based on suboptimal results after balloon angioplasty. Results: Twenty-two patients (31.4%) required at least one CdD, while nine patients (12.8%) required at least two. Intravascular lithotripsy and rotational atherectomy were the predominantly used methods(59.1% and 40.9% respectively, for in-group ratios), while ultra-high pressure and scoring balloons contributed the least to lesion preparation (9%). In 20 patients (28.5%), severe or moderate calcifications were angiographically identified, but non-compliant balloon predilation was adequate and CdD were not necessary. Total procedural time was significantly higher in CdD group (p-value 0.02). Procedural and clinical success were obtained in 100% of cases. There were no major adverse cardiac and cerebrovascular events (MACCE) recorded during hospitalization. MACCE at 1 year post-procedure were recorded in three patients (4.2% overall). All three events were documented in the control group (6.2%), and no events were recorded in CdD group (p-value 0.23). There was one cardiac death at 10 months and two target lesion revascularizations for side-branch restenosis. Conclusions: Patients with extremely calcified LM lesions treated by PCI present a favorable prognosis if angioplasty is facilitated by more aggressive lesion debulking using calcium-dedicated devices.
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Affiliation(s)
- Silviu Dumitrascu
- Faculty of Medicine, Carol Davila University of Medicine and Pharmacy, Bvd. Eroii Sanitari 8, 050474 Bucharest, Romania
- Cardiovascular Department, Jolimont Hospital, Ferrer St. 159, 7100 La Louviere, Belgium
| | - Daniela Bartos
- Faculty of Medicine, Carol Davila University of Medicine and Pharmacy, Bvd. Eroii Sanitari 8, 050474 Bucharest, Romania
| | - Claudiu Ungureanu
- Cardiovascular Department, Jolimont Hospital, Ferrer St. 159, 7100 La Louviere, Belgium
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Park S, Park SJ, Park DW. Percutaneous Coronary Intervention Versus Coronary Artery Bypass Grafting for Revascularization of Left Main Coronary Artery Disease. Korean Circ J 2023; 53:113-133. [PMID: 36914602 PMCID: PMC10011221 DOI: 10.4070/kcj.2022.0333] [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: 12/26/2022] [Accepted: 01/24/2023] [Indexed: 03/03/2023] Open
Abstract
Owing to a large-jeopardized myocardium, left main coronary artery disease (LMCAD) represents the substantial high-risk anatomical subset of obstructive coronary artery disease. For several decades, coronary artery bypass grafting (CABG) has been the "gold standard" treatment for LMCAD. Along with advances in CABG, percutaneous coronary intervention (PCI) has also dramatically evolved over time in conjunction with advances in the stent or device technology, adjunct pharmacotherapy, accumulated experiences, and practice changes, establishing its position as a safe, reasonable treatment option for such a complex disease. Until recently, several randomized clinical trials, meta-analyses, and observational registries comparing PCI and CABG for LMCAD have shown comparable long-term survival with tradeoffs between early and late risk-benefit of each treatment. Despite this, there are still several unmet issues for revascularization strategy and management for LMCAD. This review article summarized updated knowledge on evolution and clinical evidence on the treatment of LMCAD, with a focus on the comparison of state-of-the-art PCI with CABG.
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Affiliation(s)
- Sangwoo Park
- Department of Cardiology, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Korea
| | - Seung-Jung Park
- Department of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Duk-Woo Park
- Department of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea.
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Jin X, Niu K, Shen C. Recent Evidence on Advances in PCI Treatment for Left Main Coronary Artery Disease. Rev Cardiovasc Med 2022; 23:370. [PMID: 39076197 PMCID: PMC11269061 DOI: 10.31083/j.rcm2311370] [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: 03/29/2022] [Revised: 08/03/2022] [Accepted: 08/16/2022] [Indexed: 07/31/2024] Open
Abstract
Revascularization therapy significantly improves the outcomes of patients with left main coronary artery disease (LMCAD), compared with medical therapy alone. For many years, coronary artery bypass grafting (CABG) has been the primary and standard treatment strategy. However, with advances in percutaneous coronary intervention (PCI) techniques and improvements in patients' outcomes, there is growing evidence supporting PCI for LMCAD. In this review, we aim to integrate the available evidences on advances in PCI treatment for LMCAD and provide guidance for further clinical practice.
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Affiliation(s)
- Xian Jin
- Department of Cardiology, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, 200235 Shanghai, China
| | - Kaifan Niu
- Department of Cardiology, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, 200235 Shanghai, China
| | - Chengxing Shen
- Department of Cardiology, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, 200235 Shanghai, China
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Dąbrowski EJ, Kożuch M, Dobrzycki S. Left Main Coronary Artery Disease-Current Management and Future Perspectives. J Clin Med 2022; 11:jcm11195745. [PMID: 36233613 PMCID: PMC9573137 DOI: 10.3390/jcm11195745] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2022] [Revised: 09/22/2022] [Accepted: 09/26/2022] [Indexed: 02/05/2023] Open
Abstract
Due to its anatomical features, patients with an obstruction of the left main coronary artery (LMCA) have an increased risk of death. For years, coronary artery bypass grafting (CABG) has been considered as a gold standard for revascularization. However, notable advancements in the field of percutaneous coronary intervention (PCI) led to its acknowledgement as an important treatment alternative, especially in patients with low and intermediate anatomical complexity. Although recent years brought several random clinical trials that investigated the safety and efficacy of the percutaneous approach in LMCA, there are still uncertainties regarding optimal revascularization strategies. In this paper, we provide a comprehensive review of state-of-the-art diagnostic and treatment methods of LMCA disease, focusing on percutaneous methods.
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Prediction of All-Cause Mortality Following Percutaneous Coronary Intervention in Bifurcation Lesions Using Machine Learning Algorithms. J Pers Med 2022; 12:jpm12060990. [PMID: 35743777 PMCID: PMC9224705 DOI: 10.3390/jpm12060990] [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: 05/13/2022] [Revised: 06/09/2022] [Accepted: 06/14/2022] [Indexed: 11/16/2022] Open
Abstract
Stratifying prognosis following coronary bifurcation percutaneous coronary intervention (PCI) is an unmet clinical need that may be fulfilled through the adoption of machine learning (ML) algorithms to refine outcome predictions. We sought to develop an ML-based risk stratification model built on clinical, anatomical, and procedural features to predict all-cause mortality following contemporary bifurcation PCI. Multiple ML models to predict all-cause mortality were tested on a cohort of 2393 patients (training, n = 1795; internal validation, n = 598) undergoing bifurcation PCI with contemporary stents from the real-world RAIN registry. Twenty-five commonly available patient-/lesion-related features were selected to train ML models. The best model was validated in an external cohort of 1701 patients undergoing bifurcation PCI from the DUTCH PEERS and BIO-RESORT trial cohorts. At ROC curves, the AUC for the prediction of 2-year mortality was 0.79 (0.74–0.83) in the overall population, 0.74 (0.62–0.85) at internal validation and 0.71 (0.62–0.79) at external validation. Performance at risk ranking analysis, k-center cross-validation, and continual learning confirmed the generalizability of the models, also available as an online interface. The RAIN-ML prediction model represents the first tool combining clinical, anatomical, and procedural features to predict all-cause mortality among patients undergoing contemporary bifurcation PCI with reliable performance.
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11
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Scudiero F, Muraca I, Migliorini A, Marcucci R, Pennesi M, Mazzolai L, Carrabba N, Marchionni N, Stefano P, Valenti R. Outcomes of Left Main Revascularization after Percutaneous Intervention or Bypass Surgery. J Interv Cardiol 2022; 2022:6496777. [PMID: 35494423 PMCID: PMC9019449 DOI: 10.1155/2022/6496777] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2021] [Revised: 03/20/2022] [Accepted: 03/23/2022] [Indexed: 11/20/2022] Open
Abstract
Background This study is aimed at comparing the clinical outcomes of unprotected left main coronary artery disease (ULMCAD) treatment with contemporary percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG) in a "real-world" population. Methods and Results Overall, 558 consecutive patients with ULMCAD (mean age 71 ± 9 years, male gender 81%) undergoing PCI or CABG were compared. The primary endpoint was the composite of death, nonfatal myocardial infarction, or stroke. Diabetes was present in 29% and acute coronary syndrome in 56%; mean EuroSCORE was 11 ± 8. High coronary complexity (SYNTAX score >32) was present in 50% of patients. The primary composite endpoint was similar after PCI and CABG up to 4 years (15.5 ± 3.1% vs. 17.1 ± 2.6%; p=0.585). The primary end point was also comparable in a two propensity score matched cohorts. Ischemia-driven revascularization was more frequently needed in PCI than in CABG (5.5% vs. 1.5%; p=0.010). By multivariate analysis, diabetes mellitus (HR 2.00; p=0.003) and EuroSCORE (HR 3.71; p < 0.001) were the only independent predictors associated with long-term outcome. Conclusions In a "real-world" population with ULMCAD, a contemporary revascularization strategy by PCI or CABG showed similar long-term clinical outcome regardless of the coronary complexity.
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Affiliation(s)
- Fernando Scudiero
- Medical Sciences Departement, Cardiology Unit, ASST Bergamo Est, Bolognini Hospital, Seriate, Bergamo, Italy
| | - Iacopo Muraca
- Division of Interventional Cardiology, Cardiothoracovascular Department, Careggi University Hospital, Florence, Italy
| | - Angela Migliorini
- Division of Interventional Cardiology, Cardiothoracovascular Department, Careggi University Hospital, Florence, Italy
| | - Rossella Marcucci
- Department of Clinical and Experimental Medicine, University of Florence, Florence, Italy
| | - Matteo Pennesi
- Division of Interventional Cardiology, Cardiothoracovascular Department, Careggi University Hospital, Florence, Italy
| | - Lapo Mazzolai
- Division of Cardiac Surgery Unit, Cardiothoracovascular Department, Careggi University Hospital, Florence, Italy
| | - Nazario Carrabba
- Division of Interventional Cardiology, Cardiothoracovascular Department, Careggi University Hospital, Florence, Italy
| | - Niccolò Marchionni
- Department of Clinical and Experimental Medicine, University of Florence, Florence, Italy
| | - Pierluigi Stefano
- Department of Clinical and Experimental Medicine, University of Florence, Florence, Italy
- Division of Cardiac Surgery Unit, Cardiothoracovascular Department, Careggi University Hospital, Florence, Italy
| | - Renato Valenti
- Division of Interventional Cardiology, Cardiothoracovascular Department, Careggi University Hospital, Florence, Italy
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12
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Park S, Park SJ, Park DW. Percutaneous Coronary Intervention for Left Main Coronary Artery Disease: Present Status and Future Perspectives. JACC. ASIA 2022; 2:119-138. [PMID: 36339118 PMCID: PMC9627854 DOI: 10.1016/j.jacasi.2021.12.011] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Revised: 12/09/2021] [Accepted: 12/17/2021] [Indexed: 11/26/2022]
Abstract
For several decades, coronary artery bypass grafting has been regarded as the standard choice of revascularization for significant left main coronary artery (LMCA) disease. However, in conjunction with remarkable advancement of device technology and adjunctive pharmacology, percutaneous coronary intervention (PCI) offers a more expeditious approach with rapid recovery and is a safe and effective alternative in appropriately selected patients with LMCA disease. Several landmark randomized clinical trials showed that PCI with drug-eluting stents for LMCA disease is a safe option with similar long-term survival rates to coronary artery bypass grafting surgery, especially in those with low and intermediate anatomic risk. Although it is expected that the updated evidence from recent randomized clinical trials will determine the next guidelines for the foreseeable future, there are still unresolved and unmet issues of LMCA revascularization and PCI strategy. This paper provides a comprehensive review on the evolution and an update on the management of LMCA disease.
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Key Words
- BMS, bare-metal stent(s)
- CABG, coronary artery bypass grafting
- CAD, coronary artery disease
- DAPT, dual antiplatelet therapy
- DES, drug-eluting stent(s)
- DK, double-kissing
- FFR, fractional flow reserve
- IVUS, intravascular ultrasound
- LAD, left anterior descending artery
- LCX, left circumflex artery
- LMCA, left main coronary artery
- LVEF, left ventricular ejection fraction
- MACCE, major adverse cardiac or cerebrovascular events
- MI, myocardial infarction
- MLA, minimal lumen area
- PCI, percutaneous coronary intervention
- RCT, randomized clinical trial
- coronary artery bypass grafting
- iFR, instantaneous wave-free ratio
- left main coronary artery disease
- percutaneous coronary intervention
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Affiliation(s)
- Sangwoo Park
- Department of Cardiology, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, South Korea
| | - Seung-Jung Park
- Department of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Duk-Woo Park
- Department of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
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13
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Shekhar S, Mohananey D, Villablanca P, Tyagi S, Crestanello JA, Gil IJN, Ramakrishna H. Revascularization Strategies for Stable Left Main Coronary Artery Disease: Analysis of Current Evidence. J Cardiothorac Vasc Anesth 2021; 36:3370-3378. [PMID: 35115224 DOI: 10.1053/j.jvca.2021.12.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Accepted: 12/14/2021] [Indexed: 11/11/2022]
Affiliation(s)
- Shashank Shekhar
- Department of Cardiovascular Medicine, Heart, and Vascular Institute, Cleveland Clinic, Cleveland, OH
| | - Divyanshu Mohananey
- Department of Cardiovascular Medicine, Medical College of Wisconsin, Milwaukee, WI
| | | | - Sudhi Tyagi
- Department of Cardiovascular Medicine, Medical College of Wisconsin, Milwaukee, WI
| | | | - Iván J Núñez Gil
- Interventional Cardiology Consultant, Cardiovascular Institute, Hospital Clínico San Carlos, Madrid, Spain
| | - Harish Ramakrishna
- Division of Cardiovascular and Thoracic Anesthesiology, Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN.
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D'Ascenzo F, Elia E, Marengo G, Wańha W, González Ferreiro R, Truffa A, Trabattoni D, Figini F, Verardi R, Di Palma G, Infusino F, Pivato C, Ochała A, Omedè P, Milewski M, Estevez R, Raporeiras Roubin S, De Filippo O, Conrotto F, Montefusco A, Gili S, Cortese B, Dusi V, Gallone G, Manfredi R, Mancone M, Biondi Zoccai G, Casella G, Templin C, Stefanini G, Wojakowski W, Sheiban I, De Ferrari GM. Long-term (≥15 years) Follow-up of Percutaneous Coronary Intervention of Unprotected Left Main (From the GRAVITY Registry). Am J Cardiol 2021; 156:72-78. [PMID: 34325877 DOI: 10.1016/j.amjcard.2021.06.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2021] [Revised: 06/04/2021] [Accepted: 06/14/2021] [Indexed: 02/05/2023]
Abstract
Long term survival and its determinants after Percutaneous Coronary Intervention (PCI) on Unprotected Left Main Coronary Artery (ULMCA) remain to be appraised. In 9 European Centers 470 consecutive patients performing PCI on ULMCA between 2002 and 2005 were retrospectively enrolled. Survival from all cause and cardiovascular (CV) death were the primary end points, while their predictors at multivariate analysis the secondary ones. Among the overall cohort 81.5% of patients were male and mean age was 66 ± 12 years. After 15 years (IQR 13 to 16), 223 patients (47%) died, 81 (17.2%) due to CV etiology. At multivariable analysis, older age (HR 1.06, 95%CI 1.02 to 1.11), LVEF < 35% (HR 2.97, 95%CI 1.24 to 7.15) and number of vessels treated during the index PCI (HR 1.75, 95%CI 1.12 to 2.72) were related to all-cause mortality, while only LVEF <35% (HR 4.71, 95%CI 1.90 to 11.66) to CV death. Repeated PCI on ULMCA occurred in 91 (28%) patients during the course of follow up and did not significantly impact on freedom from all-cause or CV mortality. In conclusion, in a large, unselected population treated with PCI on ULMCA, 47% died after 15 years, 17% due to CV causes. Age, number of vessels treated during index PCI and depressed LVEF increased risk of all cause death, while re-PCI on ULMCA did not impact survival.
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Affiliation(s)
- Fabrizio D'Ascenzo
- Department of Medical Science, Città Della Salute e della Scienza, Division of Cardiology, Turin, Italy.
| | - Edoardo Elia
- Department of Medical Science, Città Della Salute e della Scienza, Division of Cardiology, Turin, Italy
| | - Giorgio Marengo
- Department of Medical Science, Città Della Salute e della Scienza, Division of Cardiology, Turin, Italy
| | - Wojciech Wańha
- Division of Cardiology and Structural Heart Diseases, Medical University of Silesia, Katowice, Poland
| | | | | | | | - Filippo Figini
- Division of Cardiology, Pederzoli Hospital-Peschiera del Garda, Verona, Italy
| | - Roberto Verardi
- Department of Medical Science, Città Della Salute e della Scienza, Division of Cardiology, Turin, Italy; U.O.C. Cardiologia, Ospedale Maggiore, Bologna, Italy
| | - G Di Palma
- Cardiovascular Research Team, San Carlo Clinic, Milan, Italy
| | - Fabio Infusino
- Department of Clinical, Internal, Anesthesiology and Cardiovascular Sciences, Umberto I Hospital, Sapienza University of Rome, Rome, Italy
| | - Carlo Pivato
- Cardio Center, Humanitas Clinical and Research Center IRCCS, Rozzano-Milan, Italy
| | - Andrzej Ochała
- Division of Cardiology and Structural Heart Diseases, Medical University of Silesia, Katowice, Poland
| | - Pierluigi Omedè
- Department of Medical Science, Città Della Salute e della Scienza, Division of Cardiology, Turin, Italy
| | - Marek Milewski
- Division of Cardiology and Structural Heart Diseases, Medical University of Silesia, Katowice, Poland
| | - Roi Estevez
- Department of Cardiology, University Hospital Alvaro Cunqueiro, Vigo, Spain
| | | | - O De Filippo
- Department of Medical Science, Città Della Salute e della Scienza, Division of Cardiology, Turin, Italy
| | - Federico Conrotto
- Department of Medical Science, Città Della Salute e della Scienza, Division of Cardiology, Turin, Italy
| | - Antonio Montefusco
- Department of Medical Science, Città Della Salute e della Scienza, Division of Cardiology, Turin, Italy
| | | | | | - Veronica Dusi
- Department of Molecular Medicine, Section of Cardiology, University of Pavia, Pavia, Italy
| | - Guglielmo Gallone
- Department of Medical Science, Città Della Salute e della Scienza, Division of Cardiology, Turin, Italy
| | - Roberto Manfredi
- Department of Medical Science, Città Della Salute e della Scienza, Division of Cardiology, Turin, Italy
| | - Massimo Mancone
- Department of Clinical, Internal, Anesthesiology and Cardiovascular Sciences, Umberto I Hospital, Sapienza University of Rome, Rome, Italy
| | - G Biondi Zoccai
- Department of Medical-Surgical Sciences and Biotechnologies, Sapienza University, Rome, Italy; Mediterranea Cardiocentro, Naples, Italy
| | | | - Christian Templin
- Department of Cardiology, University Heart Center, University Hospital Zurich, Zurich, Switzerland
| | - Giulio Stefanini
- Cardio Center, Humanitas Clinical and Research Center IRCCS, Rozzano-Milan, Italy
| | - Wojciech Wojakowski
- Division of Cardiology and Structural Heart Diseases, Medical University of Silesia, Katowice, Poland
| | - Imad Sheiban
- Division of Cardiology, Pederzoli Hospital-Peschiera del Garda, Verona, Italy
| | - G M De Ferrari
- Department of Medical Science, Città Della Salute e della Scienza, Division of Cardiology, Turin, Italy
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15
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Bruno F, De Filippo O, Conrotto F, D'Ascenzo F. Response to: Angiography versus FFR-guided coronary artery bypass grafting. Catheter Cardiovasc Interv 2021; 97:E1058-E1059. [PMID: 33554421 DOI: 10.1002/ccd.29542] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2021] [Accepted: 01/18/2021] [Indexed: 11/07/2022]
Affiliation(s)
- Francesco Bruno
- Division of Cardiology, Cardiovascular and Thoracic Department, Città della Salute e della Scienza Hospital and University of Turin, Torino, Italy
| | - Ovidio De Filippo
- Division of Cardiology, Cardiovascular and Thoracic Department, Città della Salute e della Scienza Hospital and University of Turin, Torino, Italy
| | - Federico Conrotto
- Division of Cardiology, Cardiovascular and Thoracic Department, Città della Salute e della Scienza Hospital and University of Turin, Torino, Italy
| | - Fabrizio D'Ascenzo
- Division of Cardiology, Cardiovascular and Thoracic Department, Città della Salute e della Scienza Hospital and University of Turin, Torino, Italy
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16
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Colombo A, Khokhar AA, Mangieri A. PCI Only for Left Main Ostial and Shaft Lesions?: Look at the Bifurcation and Beyond. JACC Cardiovasc Interv 2021; 13:2837-2839. [PMID: 33357521 DOI: 10.1016/j.jcin.2020.09.028] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2020] [Revised: 09/09/2020] [Accepted: 09/15/2020] [Indexed: 10/22/2022]
Affiliation(s)
- Antonio Colombo
- GVM Care & Research, Maria Cecilia Hospital, Cotignola, Ravenna, Italy.
| | - Arif A Khokhar
- GVM Care & Research, Maria Cecilia Hospital, Cotignola, Ravenna, Italy
| | - Antonio Mangieri
- GVM Care & Research, Maria Cecilia Hospital, Cotignola, Ravenna, Italy
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17
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Alfonso F, Gonzalo N, Rivero F, Escaned J. The year in cardiovascular medicine 2020: interventional cardiology. Eur Heart J 2021; 42:985-1003. [PMID: 33448291 PMCID: PMC7928953 DOI: 10.1093/eurheartj/ehaa1096] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2020] [Revised: 12/11/2020] [Accepted: 12/23/2020] [Indexed: 12/11/2022] Open
Affiliation(s)
- Fernando Alfonso
- Cardiology Department, Hospital Universitario de la Princesa, Instituto de Investigación Sanitaria IIS-IP, Universidad Autónoma de Madrid, CIBERCV, C/Diego de León 62, Madrid 28006, Spain
| | - Nieves Gonzalo
- Cardiology Department, Hospital Clinico San Carlos, IdISSC, Universidad Complutense de Madrid. C/ Martín Lagos s/n 28042 Madrid, Spain
| | - Fernando Rivero
- Cardiology Department, Hospital Universitario de la Princesa, Instituto de Investigación Sanitaria IIS-IP, Universidad Autónoma de Madrid, CIBERCV, C/Diego de León 62, Madrid 28006, Spain
| | - Javier Escaned
- Cardiology Department, Hospital Clinico San Carlos, IdISSC, Universidad Complutense de Madrid. C/ Martín Lagos s/n 28042 Madrid, Spain
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18
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Quality of Life After Coronary Artery Bypass Surgery: A Systematic Review and Meta-Analysis. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:ijerph17228439. [PMID: 33202650 PMCID: PMC7697861 DOI: 10.3390/ijerph17228439] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/02/2020] [Revised: 11/08/2020] [Accepted: 11/11/2020] [Indexed: 12/31/2022]
Abstract
Coronary heart disease is a public health problem and is one of the leading causes of loss of quality of life, disability, and death worldwide. The main procedure these patients undergo is cardiac catheterisation, which helps improve their quality of life, symptoms of myocardial ischemia, and ventricular function, thus helping increase the survival rate of sufferers. It can also, however, lead to physical consequences, including kidney failure, acute myocardial infarction, and stroke. The objective of this study was to analyse how coronary artery bypass grafting (CABG) influences quality of life. A systematic review and meta-analysis were conducted using the CINAHL, PubMed, Scopus, and Cuiden databases in June 2020. A total of 7537 subjects were included, 16 in the systematic review and 3 in the meta-analysis. The studies analysing quality of life using the SF questionnaire showed improvements in the quality of physical and mental appearance, and those using the NHP questionnaire showed score improvements and, in some cases, differences in quality of life between women and men. This operation seems to be a good choice for improving the quality of life of people with coronary pathologies, once the possible existing risks have been assessed.
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Bajraktari G, Zhubi-Bakija F, Ndrepepa G, Alfonso F, Elezi S, Rexhaj Z, Bytyçi I, Bajraktari A, Poniku A, Henein MY. Long-Term Outcomes of Patients with Unprotected Left Main Coronary Artery Disease Treated with Percutaneous Angioplasty versus Bypass Grafting: A Meta-Analysis of Randomized Controlled Trials. J Clin Med 2020; 9:jcm9072231. [PMID: 32674522 PMCID: PMC7408984 DOI: 10.3390/jcm9072231] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Revised: 07/04/2020] [Accepted: 07/09/2020] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND AND AIM Treatment of patients with left main coronary artery disease (LMCA) with percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG) remains controversial. The aim of this meta-analysis was to compare the long-term clinical outcomes of patients with unprotected LMCA treated randomly by PCI or CABG. METHODS PubMed, MEDLINE, Embase, Scopus, Google Scholar, CENTRAL and ClinicalTrials.gov database searches identified five randomized trials (RCTs) including 4499 patients with unprotected LMCA comparing PCI (n = 2249) vs. CABG (n = 2250), with a minimum clinical follow-up of five years. Random effect risk ratios were used for efficacy and safety outcomes. The study was registered in PROSPERO. The primary outcome was major adverse cardiac events (MACE), defined as a composite of death from any cause, myocardial infarction or stroke. RESULTS Compared to CABG, patients assigned to PCI had a similar rate of MACE (risk ratio (RR): 1.13; 95% CI: 0.94 to 1.36; p = 0.19), myocardial infarction (RR: 1.48; 95% CI: 0.97 to 2.25; p = 0.07) and stroke (RR: 0.87; 95% CI: 0.62 to 1.23; p = 0.42). Additionally, all-cause mortality (RR: 1.07; 95% CI: 0.89 to 1.28; p = 0.48) and cardiovascular (CV) mortality (RR: 1.13; 95% CI: 0.89 to 1.43; p = 0.31) were not different. However, the risk of any repeat revascularization (RR: 1.70; 95% CI: 1.34 to 2.15; p < 0.00001) was higher in patients assigned to PCI. CONCLUSIONS The findings of this meta-analysis suggest that the long-term survival and MACE of patients who underwent PCI for unprotected LMCA stenosis were comparable to those receiving CABG, despite a higher rate of repeat revascularization.
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Affiliation(s)
- Gani Bajraktari
- Department of Public Health and Clinical Medicine, Umeå University, 90737 Umeå, Sweden; (I.B.); (A.B.); (M.Y.H.)
- Clinic of Cardiology, University Clinical Centre of Kosova, 10000 Prishtina, Kosovo; (F.Z.-B.); (Z.R.); (A.P.)
- Medical Faculty, University of Prishtina “Hasan Prishtina”, 10000 Prishtina, Kosovo;
- Correspondence: ; Tel.: +37-745-80-0808
| | - Fjolla Zhubi-Bakija
- Clinic of Cardiology, University Clinical Centre of Kosova, 10000 Prishtina, Kosovo; (F.Z.-B.); (Z.R.); (A.P.)
| | - Gjin Ndrepepa
- Deutsches Herzzentrum München, Technische Universität, 80636 Munich, Germany;
| | - Fernando Alfonso
- Cardiac Department, La Princesa University Hospital, Institute of Health Research, IIS-IP, CIBER-CV University Autónoma of Madrid, 28029 Madrid, Spain;
| | - Shpend Elezi
- Medical Faculty, University of Prishtina “Hasan Prishtina”, 10000 Prishtina, Kosovo;
| | - Zarife Rexhaj
- Clinic of Cardiology, University Clinical Centre of Kosova, 10000 Prishtina, Kosovo; (F.Z.-B.); (Z.R.); (A.P.)
| | - Ibadete Bytyçi
- Department of Public Health and Clinical Medicine, Umeå University, 90737 Umeå, Sweden; (I.B.); (A.B.); (M.Y.H.)
- Clinic of Cardiology, University Clinical Centre of Kosova, 10000 Prishtina, Kosovo; (F.Z.-B.); (Z.R.); (A.P.)
| | - Artan Bajraktari
- Department of Public Health and Clinical Medicine, Umeå University, 90737 Umeå, Sweden; (I.B.); (A.B.); (M.Y.H.)
| | - Afrim Poniku
- Clinic of Cardiology, University Clinical Centre of Kosova, 10000 Prishtina, Kosovo; (F.Z.-B.); (Z.R.); (A.P.)
- Medical Faculty, University of Prishtina “Hasan Prishtina”, 10000 Prishtina, Kosovo;
| | - Michael Y. Henein
- Department of Public Health and Clinical Medicine, Umeå University, 90737 Umeå, Sweden; (I.B.); (A.B.); (M.Y.H.)
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