Long-term prognosis of chronic total occlusion treated by successful percutaneous coronary intervention in patients with or without diabetes mellitus: a systematic review and meta-analysis

Exosomes as Therapeutic and Diagnostic Tools: Advances, Challenges, and Future Directions

Exosomes are tiny extracellular vesicles that are essential for intercellular communication and have shown great promise in the detection and treatment of disease. They are especially useful in the treatment of cancer, cardiovascular conditions, and neurological diseases because of their capacity to transport bioactive substances including proteins, lipids, and nucleic acids. Because of their low immunogenicity, ability to traverse biological barriers, and biocompatibility, exosome-based medicines have benefits over conventional treatments. Large-scale production, standardization of separation methods, possible immunological reactions, and worries about unforeseen biological effects are some of the obstacles that still need to be overcome. Furthermore, there are major barriers to the clinical use of exosomes due to their complex cargo sorting mechanisms and heterogeneity. Future studies should concentrate on enhancing separation and purification procedures, optimizing exosome engineering techniques, and creating plans to reduce immune system modifications. This review examines the most recent developments in exosome-based diagnostics and treatments, identifies current issues, and suggests ways to improve their clinical translation in the future.

Impact of coronary collateralization on major adverse cardiovascular and cerebrovascular events after successful recanalization of chronic total occlusion

Aims

This study aims to investigate the effects of coronary collateral circulation (CCC) on the prognosis of chronic total occlusion (CTO) patients with or without metabolic syndrome (MetS).

Methods

The study included 342 CTO patients who underwent successful percutaneous coronary intervention at the People's Hospital of Liaoning Province between 1 February 2021 and 30 September 2023. The Rentrop score was used to assess the status of CCC. The outcome was major adverse cardiovascular and cerebrovascular events (MACCEs), defined as a composite of all-cause mortality, cardiac death, non-fatal myocardial infarction (MI), target vessel revascularization (TVR), and non-fatal stroke. Univariate and multivariate logistic analyses were used to investigate the association of CCC, MetS, and MACCEs with odds ratios (ORs) and 95% confidence intervals (CIs). The effect of CCC was further investigated in different MetS, diabetes mellitus (DM), and Syntax score groups.

Results

MACCEs were more common in patients with poor CCC compared to those with good CCC (38.74% vs. 16.56%). Statistical differences were found in MACCEs (OR = 3.33, 95% CI: 1.93-5.72), MI (OR = 3.11, 95% CI: 1.73-5.58), TVR (OR = 3.06, 95% CI: 1.70-5.53), and stent thrombosis (OR = 6.14, 95% CI: 2.76-13.65) between the good and poor CCC groups. Poor CCC patients with MetS had a higher incidence of MACCEs (OR = 4.21, 95% CI: 2.05-8.65), non-fatal MI (OR = 4.44, 95% CI: 2.01-9.83), TVR (OR = 3.28, 95% CI: 1.51-7.11), and stent thrombosis (OR = 10.80, 95% CI: 3.11-37.54). Similar findings were also observed in CTO patients with DM and a Syntax score ≥23.

Conclusion

Poor CCC could increase the risk of MACCEs in CTO patients, particularly those with MetS, DM, and a Syntax score ≥23. Further prospective, multicenter studies are needed to validate our findings and to explore potential therapeutic interventions.

Impact of Chronic Kidney Disease on Outcomes of Percutaneous Coronary Intervention in Patients With Diabetes Mellitus: A Systematic Review and Meta-Analysis

BACKGROUND

The impact of chronic kidney disease (CKD) on adverse cardiovascular outcomes after percutaneous coronary intervention in patients with diabetes mellitus (DM) is still unclear. This study aimed to systematically assess evidence on this topic.

METHODS

The PubMed, Embase, and CENTRAL databases were searched for studies comparing mortality, myocardial infarction (MI), or revascularization outcomes between patients with DM with and without CKD.

RESULTS

In 11 studies, the presence of CKD was associated with significantly increased risk of early all-cause mortality (risk ratio [RR], 3.45; 95% CI, 3.07-3.87; I2 = 0%; P < .001), late all-cause mortality (RR, 2.78; 95% CI, 1.92-4.02; I2 = 83%; P < .001), cardiac mortality (RR, 2.90; 95% CI, 1.99-4.22; I2 = 29%; P < .001), and MI (RR, 1.40; 95% CI, 1.06-1.85; I2 = 13%; P = .02) compared with no CKD. There was no difference in the risk of any revascularization between those with and without CKD. Analysis of adjusted hazard ratios (HRs) indicated significantly increased risk of mortality (HR, 2.64; 95% CI, 1.91-3.64; I2 = 0%; P < .001) in the CKD group but only a nonsignificant tendency of increased MI (HR, 1.59; 95% CI, 0.99-2.54; I2 = 0%; P = .05) and revascularization (HR, 1.24; 95% CI, 0.94-1.63; I2 = 2%; P = .12) in the CKD group.

CONCLUSION

The presence of CKD in patients with DM significantly increases the risk of mortality and MI. However, CKD had no impact on revascularization rates.

Clinical Nomogram to Predict Major Adverse Cardiac Events in Acute Myocardial Infarction Patients within 1 Year of Percutaneous Coronary Intervention

The purpose of this study was to summarize the clinical characteristics and risk factors of major adverse cardiovascular events (MACEs) in patients who had had acute myocardial infarction (AMI) within 1 year of percutaneous coronary intervention (PCI). A total of 421 AMI patients who were treated with PCI and experienced MACEs within 1 year of their admission were included in this retrospective study. In addition, patients were matched for age, sex, and presentation with 561 patients after AMI who had not had MACEs. The clinical characteristics and risk factors for MACEs within 1 year in AMI patients were investigated, to develop a nomogram for MACEs based on univariate and multivariate analyses. The C statistic was used to assess the discriminative performance of the nomogram. In addition, calibration curve and decision curve analyses were conducted to validate the calibration performance and utility, respectively, of the nomogram. After univariate and multivariate analyses, a nomogram was constructed based on age (odds ratio (OR): 1.030; 95% confidence interval (CI): 1.014–1.047), diabetes mellitus (OR: 1.667; 95% CI: 1.151–2.415), low-density lipoprotein cholesterol (OR: 1.332; 95% CI: 1.134–1.565), uric acid (OR: 1.003; 95% CI: 1.001–1.005), lipoprotein (a) (OR: 1.003; 95% CI: 1.002–1.003), left ventricular ejection fraction (OR: 0.929; 95% CI: 0.905–0.954), Syntax score (OR: 1.075; 95% CI: 1.053–1.097), and hypersensitive troponin T (OR: 1.002; 95% CI: 1.002–1.003). The C statistic was 0.814. The calibration curve showed good concordance of the nomogram, while decision curve analysis demonstrated satisfactory positive net benefits. We developed a convenient, practical, and effective prediction model for predicting MACEs in AMI patients within 1 year of PCI. To ensure generalizability, this model requires external validation.

5-Year Clinical Outcomes of Successful Recanalisation for Coronary Chronic Total Occlusions in Patients With or Without Type 2 Diabetes Mellitus

Background: Despite substantial improvement in chronic total occlusions (CTO) revascularization technique, the long-term clinical outcomes in diabetic patients with revascularized CTO remain controversial. Our study aimed to investigate the 5-year cardiovascular survival for patients with or without type 2 diabetes mellitus (DM) who underwent successful percutaneous coronary intervention (PCI) for CTO. Methods: Data of the current analysis derived from a large single-center, prospective and observational cohort study, including 10,724 patients who underwent PCI in 2013 at Fuwai Hospital. Baseline, angiographic and follow-up data were collected. The primary endpoint was major adverse cardiac and cerebrovascular events (MACCE), which consisted of death, recurrent myocardial infarction (MI), stroke and target vessel revascularization (TVR). The secondary endpoint was all-cause mortality. Cox regression analysis and propensity-score matching was performed to balance the baseline confounders. Results: A total of 719 consecutive patients with ≥1 successful CTO-PCI were stratified into diabetic (n = 316, 43.9%) and non-diabetic (n = 403, 56.1%) group. During a median follow-up of 5 years, the risk of MACCE (adjusted hazard ratio [HR] 1.47, 95% confidence interval [CI] 1.08-2.00, P = 0.013) was significantly higher in the diabetic group than in the non-diabetic group, whereas the adjusted risk of all-cause mortality (HR 2.37, 95% CI 0.94-5.98, P = 0.068) was similar. In the propensity score matched population, there were no significant differences in the risk of MACCE (HR 1.27, 95% CI 0.92-1.75, P = 0.155) and all-cause mortality (HR 2.56, 95% CI 0.91-7.24, P = 0.076) between groups. Subgroup analysis and stratification analysis revealed consistent effects on 5-year MACCE across various subgroups. Conclusions: In patients who received successful CTO-PCI, non-diabetic patients were related to better long-term survival benefit in terms of MACCE. The risk of 5-year MACCE appeared to be similar in less-controlled and controlled diabetic patients after successful recanalization of CTO. Further randomized studies are warranted to confirm these findings.

Impact of diabetes mellitus on outcomes of percutaneous coronary intervention in chronic total occlusions: A systematic review and meta-analysis

BACKGROUND

Patients with diabetes mellitus (DM) have a high prevalence of coronary chronic total occlusions (CTOs). We conducted a systematic review and meta-analysis to characterize outcomes after CTO percutaneous coronary intervention (PCI) in patients without or with DM.

METHODS

PubMed, EMBASE, Cochrane, and Google Scholar were queried for studies comparing non-DM vs. DM patients undergoing attempted CTO PCI. The primary outcome was all-cause mortality at longest follow-up (at least 6 months). Secondary outcomes were major adverse cardiovascular events (MACE) which is a composite endpoint including myocardial infarction, cardiac or all-cause mortality and any revascularization in patients after CTO PCI, target vessel revascularization (TVR), myocardial infarction (MI), Japanese chronic total occlusion (J-CTO) score and prevalence of multivessel (MV) CTO disease. We used a random effects model to calculate odds ratios (ORs) and 95% confidence intervals (CIs).

RESULTS

Sixteen studies, including 2 randomized control trials and 14 observational studies, met inclusion criteria. At longest follow-up, all-cause mortality (OR 0.54 [95% CI 0.37-0.80], p < 0.0001) and MACE (OR 0.82 [95% CI 0.72-0.93], p < 0.00001) were significantly lower in non-DM CTO patients. MV CTO disease was less prevalent in patients without DM (OR 0.80 [95% CI 0.69-0.93], p = 0.004). However, there were no differences in MI, TVR and J-CTO score.

CONCLUSIONS

Non-diabetics undergoing CTO PCI have lower all-cause mortality and MACE than diabetics. Future research may determine if DM control improves diabetics' CTO PCI outcomes.

Metabolic syndrome and its components reduce coronary collateralization in chronic total occlusion: An observational study

BACKGROUND

Metabolic syndrome (MetS) is an independent risk factor for the incidence of cardiovascular diseases. We investigated whether or to what extent MetS and its components was associated with coronary collateralization (CC) in chronic total occlusion (CTO).

METHODS

This study involved 1653 inpatients with CTO. Data on demographic and clinical characteristics were collected by cardiovascular doctors. The CC condition was defined by the Rentrop scoring system. Subgroup analysis, mixed model regression analysis, scoring systems and receiver operating characteristic (ROC) curve analysis were performed.

RESULTS

Overall, 1653 inpatients were assigned to the poor CC group (n = 355) and good CC group (n = 1298) with or without MetS. Compared to the good CCs, the incidence of MetS was higher among the poor CCs for all patients. Poor collateralization was present in 7.6%, 14.2%, 19.3%, 18.2%, 35.6% and 51.1% of the six groups who met the diagnostic criteria of MetS 0, 1, 2, 3, 4 and 5 times, respectively. For multivariable logistic regression, quartiles of BMI remained the risk factors for CC growth in all subgroups (adjusted OR = 1.755, 95% CI 1.510-2.038, P < 0.001 all patients; adjusted OR = 1.897, 95% CI 1.458-2.467, P < 0.001 non-MetS; and adjusted OR = 1.814, 95% CI 1.482-2.220, P < 0.001 MetS). After adjustment for potential confounding factors, MetS was an independent risk factor for CC growth in several models. Assigning a score of one for each component, the AUCs were 0.629 (95% CI 0.595-0.662) in all patients, 0.656 (95% CI 0.614-0.699) in MetS patients and 0.569 (95% CI 0.517-0.621) in non-MetS patients by receiver operating characteristic analysis.

CONCLUSIONS

MetS, especially body mass index, confers a greater risk of CC formation in CTO. The value of scoring systems should be explored further for CTO.