Applied coronary physiology for planning and guidance of percutaneous coronary interventions. A clinical consensus statement from the European Association of Percutaneous Cardiovascular Interventions (EAPCI) of the European Society of Cardiology

The clinical value of fractional flow reserve and non-hyperaemic pressure ratios are well established in determining an indication for percutaneous coronary intervention (PCI) in patients with coronary artery disease (CAD). In addition, over the last 5 years we have witnessed a shift towards the use of physiology to enhance procedural planning, assess post-PCI functional results, and guide PCI optimisation. In this regard, clinical studies have reported compelling data supporting the use of longitudinal vessel analysis, obtained with pressure guidewire pullbacks, to better understand how obstructive CAD contributes to myocardial ischaemia, to establish the likelihood of functionally successful PCI, to identify the presence and location of residual flow-limiting stenoses and to predict long-term outcomes. The introduction of new functional coronary angiography tools, which merge angiographic information with fluid dynamic equations to deliver information equivalent to intracoronary pressure measurements, are now available and potentially also applicable to these endeavours. Furthermore, the ability of longitudinal vessel analysis to predict the functional results of stenting has played an integral role in the evolving field of simulated PCI. Nevertheless, it is important to have an awareness of the value and challenges of physiology-guided PCI in specific clinical and anatomical contexts. The main aim of this European Association of Percutaneous Cardiovascular Interventions clinical consensus statement is to offer up-to-date evidence and expert opinion on the use of applied coronary physiology for procedural PCI planning, disease pattern recognition and post-PCI optimisation.

Prevalence of abnormalities on cardiac MRI in unselected patients after recovery from acute SARS-CoV-2 infection and correlation with markers of immunity and coagulation: the SETANTA study

Background

Previous studies have reported ongoing cardiac inflammation as assessed by cardiac magnetic resonance imaging (CMR) in a significant proportion of patients several months after recovery from SARS-CoV-2 infection, many of whom had no or minimal symptoms at the time of infection.

Purpose

The aim of SETANTA was to investigate the prevalence of cardiac abnormalities by CMR in unselected patients in Ireland after acute SARS-CoV-2 infection and the correlation with immunological response and biomarkers of coagulation.

Methods

This was a prospective, observational, community-based study (clinicaltrials.gov identifier NCT04823182). Consecutive patients recovered from recent SARS-CoV-2 infection at 3 primary care sites were invited to participate. Key inclusion/exclusion criteria and outcomes of interest are shown in Figure 1.

Results

100 participants were enrolled (Feb-Sept 2021) at a median of 188 (IQR, 125, 246) days after positive SARS-CoV-2 swab. At index infection, 18% and 35% reported severe and moderate symptoms, respectively; 14% were hospitalized; 3% were admitted to intensive care for ventilatory support. At enrolment, 83% had ongoing symptoms. 85% had detectable SARS-CoV-2 antigens. CMR and laboratory findings are shown in Figure 1.

Conclusion

Among an unselected cohort of patients recovered from acute SARS-CoV2 infection, we report a low prevalence of cardiac abnormalities by CMR, despite a high prevalence of moderate/severe symptoms at presentation and a high prevalence of persistent symptoms. Correlation with biomarkers of immunity and coagulation will be available at ESC 2022.

Funding Acknowledgement

Type of funding sources: Foundation. Main funding source(s): WomenAsOne

Initial experience and validation of a novel tool to assess patient experience in the catheterization laboratory (PATCATH), in patients undergoing coronary angiography or angioplasty

Funding Acknowledgements

Type of funding sources: None.

Background

Patient-reported experience metric (PREM) questionnaires are an important tool for evaluating patient experience.

Purpose

Validated PREM tools may help to identify areas of quality improvement within healthcare.

Methods

A novel tool developed by the Patient Initiative Committee of the European Association of Percutaneous Intervention (EAPCI), in association with the European Society of Cardiology Patient Forum was designed to capture patient experience in the catherization laboratory. The questionnaire is divided into 3 domains assessing experience before, during and after coronary angiography or angioplasty (Figure 1, Panels A-C). Responses were recorded on a scale of strongly agree, agree, disagree, or strongly disagree. Consecutive patients undergoing a coronary angiography or angioplasty received the questionnaire to complete anonymously during recovery following catheterization.

Results

A total of 100 valid responses were received over a four week pilot experience. Most patients had an angiogram procedure (80%). A total of 52% were grouped in the higher age category (≥66 years) (Table 1). Patient response indicated a high level of satisfaction with the experience before the procedure: 98.6% of patients strongly agreed or agreed with statements assessing positive experience reflecting a level of knowledge of why the procedure was recommended and perceived level of support (Figure 1, Panel A). 98.5% strongly agreed or agreed with statements assessing positive experience of comfort, safety, communication and understanding during the procedure (Figure 1, Panel B). A total of 9.6% of patients within the higher age category provided no response regarding their understanding for why a treatment decision was made, whilst all patients in the lower age category responded. After the procedure, 59.3% strongly agreed or agreed with statements assessing positive experience: with lower levels of positive experience for questions related to lifestyle changes (60%), comprehension of a rehabilitation program (46%), medication prescription (58%) and treatment duration (53%) (Figure 1, Panel C). However, 15.2% of questions in this domain had no response, particularly those related to prescribed medication. A lower positive experience was observed between higher versus lower age categories respectively (44.2% & 77.1%) regarding an understanding of necessary lifestyle changes.

Conclusion

The results of our initial experience with a novel PREMs tool highlight high levels of positive experience before and after diagnostic angiography and a lower level of positive experience in the period after the procedure. Completing this tool at a later stage or post-hospital discharge (i.e., following additional education interventions) may help to capture a higher positive response related to after the intervention. To validate these findings, this PREM tool should be evaluated further in additional patient cohorts across multiple sites.

A meta-analysis of randomised controlled trials investigating the impact of colchicine on major adverse cardiovascular events in acute coronary syndrome

Background/Introduction

Colchicine has been shown to reduce inflammation and has a potential to stabilise atherosclerotic plaques. Prior meta-analyses on the topic suggest its role in reducing components of major adverse cardiovascular events (MACE).

Purpose

The aim of the present meta-analysis was to delineate the effect of colchicine on post-PCI (percutaneous intervention) MACE among acute coronary syndrome (ACS) patients.

Methods

We included randomised controlled trials (RCTs) comparing colchicine to placebo in ACS patients undergoing PCI. To identify potentially relevant trials a PUBMED search was undertaken using the MESH terms “colchicine” and “cardiovascular system”. Eligible RCTs published up to November 2020 were included. Our search strategy also included presentations from the proceedings of international meetings. The primary endpoint was MACE. However, definitions of MACE varied between included studies. Study level odds ratios (ORs) and 95% confidence intervals (CI) of MACE were pooled using the Mantel-Haenszel method and random effects model. Forest plots were generated using Review Manager (RevMan) 5.4 software.

Results

Our initial search identified 1,049 articles for potential inclusion. Of them, 4 RCTs were found to be eligible: COPS, COLCHICINE-PCI, COLCOT time-to-Initiation (TTI) 0–3 days and PODCAST-PCI.

A pool of 2,709 patients were randomly allocated to treatment with either colchicine (n=1,367) or placebo (n=1,342). Patients received colchicine either prior to angiography or within 3 days post-procedure. Follow up duration ranged from 30 days to 3 years during which MACE were recorded. Mean age of the whole analysed cohort was 60.3±10.5 years. 73% were male. 51% had history of hypertension, 26% had diabetes mellitus, 38% were current smokers. There were 89 events in the colchicine group as opposed to 133 events in the placebo group. The risk of post-PCI MACE was lower in patients treated with colchicine as compared with placebo (OR 0.63, 95% CI 0.48–0.84, p=0.001) (see figure 1). Heterogeneity was not detectable (I2=0).

Conclusions

Our results indicate lower risk of MACE in patients treated with colchicine. This indicates a potential use of colchicine in patients undergoing PCI in an ACS setting. Further investigations in larger cohorts are warranted to test this effect.

Funding Acknowledgement

Type of funding sources: None. Figure 1

Interleukin 6 –174 G/C polymorphism: its relation to coronary artery disease and circulating IL-6 levels – a systematic review and meta-analysis

Introduction

Circulating IL-6 levels and at least one polymorphic form of IL6 gene (IL6 –174 G/C, rs1800795) have been found to be independently associated with coronary artery disease (CAD). However, the association status of this polymorphism with CAD remains unclear.

Purpose

We conducted a systematic review and updated meta-analysis to comprehensively ascertain the association status of IL6 –174 G/C with CAD and its effect on the levels of circulating IL-6 in humans.

Methods

Comprehensive online search was undertaken to find relevant case-control/cohort studies investigating the association of IL6 –174 G/C with CAD. The association status of –174 G/C with CAD amongst pooled sample as well as separately amongst different ancestral populations was assessed. Association of –174 G/C with circulating IL-6 levels was also assessed amongst pooled sample as well as separately for CAD cases and CAD-free controls. Study-level odds ratios (OR) and 95% confidence intervals (CI) were pooled by Mantel-Haenszel fixed-effects models.

Results

Quantitative synthesis for assessing the role of this polymorphic variant in CAD was performed using 55 separate qualifying studies with a collective sample size of 51,213 (19,160 cases / 32,053 controls). The pooled association of –174 G/C with CAD was found to be statistically significant through dominant (OR= 1.15, 95% CI= 1.05–1.25, p=0.002) as well as allelic genetic model comparisons (OR= 1.13, 95% CI= 1.06–1.21, p=0.0003). Asian and Asian-Indian ancestral subgroups showed significant association with CAD in both genetic model comparisons (OR range= 1.29 to 1.53, p value range ≤0.02). Other ancestral subgroups did not show any meaningful association. Circulating IL-6 levels were found to be significantly higher amongst the “C” allele carriers in the pooled sample (Standard mean difference, SMD= 0.31, 95% CI= 0.01–0.22 pg/ml, p=0.009) as well as the CAD-free control subgroup (SMD= 0.10, 95% CI= 0.02–0.17 pg/ml, p=0.009). CAD case subgroup did not show any significant association (p=0.12).

Conclusions

The present systematic review and meta-analysis confirms an association between IL6 –174 G/C polymorphism residing in the IL6 gene and CAD, especially amongst Asian and Asian-Indian ancestral groups. Upregulation of plasma IL-6 levels in the “C” allele carriers seem to be at least partly responsible for the observed association. Further investigations with large structured case-control studies amongst these ancestral groups are warranted.

Funding Acknowledgement

Type of funding sources: None.

Antithrombotic therapy with or without aspirin after percutaneous coronary intervention or acute coronary syndrome in patients taking oral anticoagulation: A meta-analysis and network analysis of randomized controlled trials

INTRODUCTION

Trials investigating aspirin omission in patients taking oral anticoagulation (OAC) after percutaneous coronary intervention (PCI) or acute coronary syndrome (ACS) were not powered to assess rates of major bleeding or ischemic events.

METHODS

We performed an updated meta-analysis and network analysis of randomized trials comparing treatment with or without aspirin in patients taking OAC and a P2Y12-inhibitor after PCI or ACS. The primary outcome was TIMI major bleeding.

RESULTS

Five trials enrolling 11,542 patients allocated to antithrombotic regimens omitting (n = 5795) or including aspirin (n = 5747) were included. Aspirin omission was associated with a lower risk of TIMI major bleeding (RR = 0.56, 95% CI [0.44-0.71]; P < 0.001) but a trend towards a higher risk of MI (RR = 1.21, 95% CI [0.99-1.47]; P = 0.06), which was significantly higher when only non-vitamin K antagonist OAC (NOAC)-based trials were considered (P_interaction = 0.02). The risk of stent thrombosis was comparable with both strategies (RR = 1.29, 95% CI [0.87-1.90]; P = 0.20), with a trend towards a higher risk of ST with aspirin omission when only NOAC-based trials were considered (P_interaction = 0.06). Risks of stroke and death were similar with both strategies. Network meta-analysis ranked dabigatran (low dose) without aspirin as the best strategy for bleeding reduction (P-score = 0.86) and apixaban with aspirin as the best strategy for MI reduction (P-score = 0.66).

CONCLUSIONS

In patients taking OAC after PCI or ACS, aspirin omission is associated with a lower risk of TIMI major bleeding, with a numerically increased risk of MI, which is statistically significant when only NOAC-based trials are considered. This supports individualization of the treatment regimen based on patient risk.

Design and rationale of a randomized trial of COBRA PzF stenting to REDUCE duration of triple therapy (COBRA-REDUCE)

BACKGROUND/PURPOSE

A coronary stent with thromboresistant and pro-healing properties such as the polymer polyzene F-coated (COBRA PzF) stent might safely allow for a very short duration of triple therapy in patients taking oral anticoagulation (OAC) who undergo coronary stenting.

METHODS

The COBRA-REDUCE trial is a prospective, multinational, randomized, open-label, assessor-blinded trial. A total of 996 patients at high bleeding risk because of requirement for OAC (with a vitamin K antagonist or non-vitamin K antagonist for any indication) will be randomized at sites in the United States and Europe to treatment with the COBRA-PzF stent followed by very short duration (14 days) DAPT or a Food and Drug Administration (FDA)-approved new generation drug-eluting stent followed by guideline-recommended DAPT duration (3 or 6 months). Two co-primary endpoints will be tested at 6 months: a bleeding co-primary endpoint (bleeding academic research consortium [BARC] ≥2 bleeding beyond 14 days or after hospital discharge, whichever is later [superiority hypothesis]) and a thrombo-embolic co-primary endpoint (the composite of all-cause death, myocardial infarction, definite/probable stent thrombosis or ischaemic stroke [non-inferiority hypothesis]). The trial is registered at clinicaltrials.gov (NCT02594501).

CONCLUSION

The COBRA-REDUCE trial will determine whether coronary stenting with the COBRA PzF stent followed by 14 days of clopidogrel will reduce bleeding without increasing thrombo-embolic events compared with FDA-approved DES followed by 3-6 months clopidogrel in patients taking OAC and aspirin.

P5630Morphometric and qualitative differences in neointimal tissue six months after implantation of bioresorbable scaffolds versus conventional everolimus eluting stents in ISAR-Absorb MI trial

Background

Bioresorbable scaffolds (BRS) are novel devices designed to overcome the long-term limitations of permanent metallic stent implantation. Optical coherence tomography (OCT) surveillance can provide important insights on the process of vessel wall healing at follow-up.

Purpose

We sought to compare OCT-assessed healing at 6 months after implantation of everolimus-eluting BRS and everolimus-eluting metallic stents (EES) in patients treated for acute myocardial infarction (AMI).

Methods

ISAR-Absorb MI is a multicentre, 2:1 randomized trial comparing outcomes of patients with AMI stented with BRS or conventional EES. Angiographic surveillance was planned for all patients at 6–8 months follow-up. Patients who had OCT surveillance at follow-up were included for the present analysis. Analysis of contiguous OCT cross-sections- 1 mm apart was performed at a centralized core laboratory. Tissue characterisation using a 256-level grey-scale signal intensity (GSI) analysis was also performed for all neointimal regions of interest (ROI) with thickness of 100 to 400 μm. ROI's were classified as mature using a standard cut-off GSI score of 109.7. Generalised linear mixed model (GLMM) was used as appropriate. Statistical analysis was performed using R software. Data is presented as numbers, percentages or median (Interquartile range, IQR).

Results

Median follow-up interval was 216 days. 70 patients in the BRS arm and 33 patients in the EES arm were available for analysis. Stented length was 19.8 mm (13.6, 24.5) and 22.3 mm (16.7, 26.4) in BRS and EES arms respectively (p=0.73). Minimum lumen area [5.13 (3.95, 6.71) vs. 4.83 (3.63, 6.92) mm2] and minimum stent area [5.78 (4.88, 7.34) vs. 6.36 (4.70, 7.45) mm2] were comparable between BRS and EES.

2,262 frames (1,529 in BRS, 733 in EES) with 20,033 struts (12,704 in BRS, 7,329 in EES) were assessed. Overall strut coverage was better with BRS compared to EES (97.5% vs. 91.1% respectively, p<0.001). Malapposed (1.1% vs. 0.5%, p=0.54) and uncovered struts (7.3% vs. 1.3%, p<0.001) were more common with EES. Neointimal coverage was comparable amongst both stent groups [85.5 (61.9, 124.1) vs. 71.5 (33.4, 133.0) μm in BRS and EES groups respectively, p=0.50].

GSI analysis in 95 cases (65 cases, 2,233 ROIs in BRS; 30 cases, 1,210 ROIs in EES) showed that immature ROIs were numerically more common in the EES group as compared to the BRS group (75.4 vs. 57.0% respectively; p=0.35).

Two-year clinical follow-up and analysis of correlation of clinical outcomes with OCT findings will also be available for presentation at ESC Congress 2019.

Conclusions

In selected patients undergoing OCT imaging at 6–8 months after implantation of BRS and conventional EES for AMI, we observed generally favourable healing characteristics with high rates of strut coverage, low rates of strut malapposition and fewer areas of immature neointimal areas with BRS in comparison to EES.

Acknowledgement/Funding

The study was predominantly funded by Deutsches Herzzentrum München and in part by a grant from Abbott Vascular