Interhospital and interindividual variability in secondary prevention: a comparison of outpatients with a history of chronic coronary syndrome versus outpatients with a history of acute coronary syndrome (the iASPIRE Study)

Background

Studying variability in the care provided to secondary prevention coronary heart disease (CHD) outpatients can identify interventions to improve their outcomes.

Methods

We studied outpatients who had an index CHD event in the preceding 6–24 months. Eligible CHD events included acute coronary syndrome (ACS) and coronary revascularisation for stable chronic coronary syndrome (CCS). Site training was provided by a core team and data were collected using standardised methods.

Results

Between 2017 and 2019, we enrolled 721 outpatients at nine Irish study sites; 81% were men and mean age was 63.9 (SD ±8.9) years. The study examination occurred a median of 1.16 years after the index CHD event, which was ACS in 399 participants (55%) and stable-CCS in 322. On examination, 42.5% had blood pressure (BP) >140/90 mm Hg, 63.7% had low-density lipoprotein cholesterol (LDL-C) >1.8 mmol/L and 44.1% of known diabetics had an HbA1c >7%. There was marked variability in risk factor control, both by study site and, in particular, by index presentation type. For example, 82% of outpatients with prior-ACS had attended cardiac rehabilitation versus 59% outpatients with prior-CCS (p<0.001) and there were also large differences in control of traditional risk factors like LDL-C (p=0.002) and systolic BP (p<0.001) among outpatients with prior-ACS versus prior-CCS as the index presentation.

Conclusions

Despite international secondary prevention guidelines broadly recommending the same risk factor targets for all adults with CHD, we found marked differences in outpatient risk factor control and management on the basis of hospital location and index CHD presentation type (acute vs chronic). These findings highlight the need to reduce hospital-level and patient-level variability in preventive care to improve outcomes; a lesson that should inform CHD prevention programmes in Ireland and around the world.

Collagen embolization for the successful treatment of a distal coronary artery perforation

A 42-year old man suffered a coronary artery perforation in the right coronary artery secondary to a hydrophilic guidewire. We describe for the first time the use of collagen embolization to successfully treat this complication.

Digital enhancement of stent images in primary and secondary percutaneous coronary revascularisation

Inadequate stent expansion and apposition during percutaneous coronary intervention increases the risk of subsequent restenosis and thrombosis. In repeat and complex percutaneous interventions, such as treatment of stent restenosis or bifurcation techniques, these aspects present a renewed importance. Intravascular ultrasound (IVUS) constitutes the standard technique to assess stent expansion, but its use in clinical practice is far from being universal. Although most current stent designs are radiolucent, new radiological imaging modalities, specifically tailored to coronary stent imaging, can render images with enough quality to visualise stent sub-expansion. While this approach might be complementary to IVUS in clinical practice, few in vivo studies comparing both techniques are available. In this article we review the principles of digital enhancement of stent images and the available validation studies. Furthermore, we report on a comparison between IVUS and digital enhancement stent images performed after coronary stenting.

Intravascular ultrasound guidance of multiple drug-eluting stent implantation in lesions associated with coronary aneurysms

Treatment of lesions associated with coronary artery aneurysms (CAA) remains a challenge. This is especially true in patients presenting with multiple CAA. We, therefore, describe a case of a 48-year-old male with severe multivessel disease related to CAA who was treated using drug-eluting stents to address the stenoses located at the CAA edges. The value of intravascular ultrasound to guide and optimize the results of this complex intervention is emphasized.