Meta-analysis of long-term outcomes of percutaneous coronary intervention versus medical therapy in stable coronary artery disease

Predictors of restenosis following percutaneous coronary stent implantation: The role of trimetazidine therapy

Aims

In-stent restenosis (ISR) is an unresolved problem following percutaneous coronary intervention (PCI), having a negative impact on clinical outcome. The main goal of this study was to find new independent predictors that may influence the development of ISR.

Methods and results

In this retrospective analysis, 653 PCI patients were involved. All patients had coronary stent implantation and a follow-up coronary angiography. Based on the presence of ISR at follow-up, patients were divided into two groups: 221 in the ISR and 432 in the control group. When evaluating the medical therapy of patients, significantly more patients were on trimetazidine (TMZ) in the control compared to the ISR group (p = 0.039). TMZ was found to be an independent predictor of a lower degree of ISR development (p = 0.007). TMZ treatment was especially effective in bare metal stent (BMS)-implanted chronic coronary syndrome (CCS) patients with narrow coronary arteries. The inflammation marker neutrophil to lymphocyte ratio (NLR) was significantly elevated at baseline in the ISR group compared to controls. The reduction of post-PCI NLR was associated with improved efficacy of TMZ to prevent ISR development. Drug eluting stent implantation (p < 0.001) and increased stent diameter (p < 0.001) were the most important independent predictors of a lower degree of ISR development, while the use of longer stents (p = 0.005) was a major independent predictor of an increased ISR risk.

Conclusion

TMZ reduces the occurrence of ISR following PCI, with special effectiveness in BMS-implanted patients having CCS and narrow coronary arteries. TMZ treatment may help to lower ISR formation in countries with high BMS utilization rates.

Invasive therapy versus conservative therapy for patients with stable coronary artery disease: An updated meta-analysis

Background

Heart disease remains the leading cause of death in the United States. Although there are clear indications for revascularization in patients with acute coronary syndromes, there is debate regarding the benefits of revascularization in stable ischemic heart disease. We sought to perform a comprehensive meta‐analysis to assess the role of revascularization compared to conservative medical therapy alone in patients with stable ischemic heart disease.

Hypothesis

There is no significant difference in all‐cause mortality or cardiovascular mortality between invasive and medical arms.

Methods

We performed a systematic literature search from January 2000 to June 2020. Our literature search yielded seven randomized controlled trials. We analyzed a total of 12 013 patients (6109 in revascularization arm and 5904 in conservative medical therapy arm). Primary outcome was all‐cause mortality. Secondary outcomes included major adverse cardiac events (MACE) (death, myocardial infarction [MI], or stroke), cardiovascular mortality, MI, and stroke. Additional subgroup analysis for all‐cause mortality was performed comparing percutaneous coronary intervention (PCI) with bare metal stent versus conservative therapy; and PCI with drug eluting stent versus conservative therapy.

Results

There was no statistically significant difference in primary outcome of all‐cause mortality between either arm (odds ratio [OR] = 0.95; 95% CI [confidence interval], 0.83 to 1.08; p = .84). There were statistically significant lower rates of MACE (death, MI or stroke) in the revascularization arm when compared to conservative arm.

Conclusions

Our analysis did not show any survival advantage of an initial invasive strategy over conservative medical therapy in patients with stable coronary artery disease (CAD).

Long-term impact of baseline anaemia on clinical outcomes following percutaneous coronary intervention in stable angina

Background

In patients with stable angina (SA), the clinical benefits of percutaneous coronary intervention (PCI) reside almost exclusively within the realm of symptomatic improvement rather than improvement in hard clinical endpoints. The benefits of PCI should always be balanced against its potential short-term and long-term risks. Common among these risks is the presence of anaemia and its interaction with poor clinical outcomes and increased morbidity; this study aims to elucidate the impact of anaemia on long-term clinical outcomes of this patient group.

Methods

From Danish national registries, we identified patients with SA treated with PCI who had a haemoglobin measurement maximum of 90 days prior to PCI procedure. Anaemia was defined as haemoglobin <130 and <120 g/L in men and women, respectively. Follow-up was up to 3 years after PCI, and Cox regression was used to estimate HRs with 95% CIs of hospitalisation due to bleeding, acute coronary syndrome (ACS) and all-cause mortality in patients with anaemia compared with patients without anaemia.

Results

Of 2837 included patients, 14.6% had anaemia prior to PCI. During follow-up, 93 patients (3.3%) had a bleeding episode, which was higher in patients with anaemia (5.8%) compared with patients without anaemia (2.8%). A total of 213 patients (7.5%) developed ACS, which was higher in patients with anaemia (10.6%) compared with patients without anaemia (7.0%). Furthermore, 185 patients (6.5%) died, with a mortality rate of 18.1% in patients with anaemia compared with 4.5% in patients without anaemia. In multivariable analyses, anaemia was associated with a significantly increased risk of bleeding (HR 1.69; 95% CI 1.04 to 2.73; P 0.033), ACS (HR 1.47; 95% CI 1.04 to 2.10; P 0.031) and all-cause mortality (HR 2.41; 95% CI 1.73 to 3.30; P <0.001).

Conclusion

Anaemia in patients with SA was significantly associated with bleeding, ACS and all-cause mortality following PCI.

Proposed method for evaluation and categorization of functional capacity of children, adolescents, and adults with cardiac diseases to bring them in existing social justice system by creating the cardiac disability criteria

INTRODUCTION

Emerging epidemiological trends in India indicate the rising burden of cardiovascular diseases (CVDs) demanding a need of a social support system. Yet, the list of 21 benchmark disabilities notified by the Department of Empowerment of Persons with Disabilities, Ministry of Social Justice and Empowerment, Government of India, does not include CVDs under the newly enacted Rights of Persons with Disabilities (RPWD) Act, 2016. While the RPWD Act 2016 has acknowledged the dynamic nature of disabilities associated with congenital diseases like thalassemia, it has also provided an opportunity to bring in "cardiac disability" under its tenets. This would allow India to adopt strategies for the benefit of cardiac patients in accordance with policies adopted by developed countries such as the United States of America (USA), the United Kingdom of Great Britain (UK), and Canada. This document is to initiate a thought process of recruitment of cardiac patients in the social justice system.

AIMS AND OBJECTIVES

(1) To define cardiac disability, (2) to categorize cardiac diseases/defects (groups A-C) according to severity and need for interventions, (3) to identify operated and unoperated patients with normal functional capacity and their eligibility to avail normal opportunities similar to their peer groups, (4) to create a comprehensive cardiac disability scoring (CCDS) system for disability certification based on subjective and objective evaluation of functional capacity and the corresponding heart disease category group, and (5) to create a reference literature for the issues of education, employability, insurability, and vocational counseling based on this document.

METHODOLOGY

The evolution of this manuscript has been discussed in view of relevant observations made by a team of cardiologists, cardiac surgeons, intensivists, pediatricians, social workers, etc.

CONCLUSION

This manuscript suggests a CCDS system to lay down criteria for disability status for eligible patients suffering from cardiovascular diseases. It intends to offer a unique scientific tool to address the psychosocial and socio-economic bias against patients with heart diseases of heterogeneous nature.