Circulation: Cardiovascular Interventions最新文献

Background: Microaxial flow pump (mAFP) use in selected patients with ST-segment-elevation myocardial infarction complicated by cardiogenic shock improves survival. The present study aimed to assess the influence of delay from first symptoms to randomization on the benefit of an mAFP in patients with ST-segment-elevation myocardial infarction complicated by cardiogenic shock.

Methods: This was a secondary analysis of the international, multicenter, randomized, open-labeled DanGer Shock trial (Danish-German Cardiogenic Shock). A total of 345 of 355 patients with ST-segment-elevation myocardial infarction and cardiogenic shock were enrolled in this substudy. Patients were stratified into quartiles according to delay from first symptoms to randomization to either an mAFP or standard care alone. The end point was death from any cause at 180 days for treatment with an mAFP versus standard of care, according to time from onset of symptoms to randomization obtained by logistic regression analysis.

Results: Mortality at 180 days increased across quartiles of time from onset of symptoms to randomization: Q1 (0-140 minutes), 36%; Q2 (141-248 minutes), 53%; Q3 (249-650 minutes), 59%; and Q4 (> 651 minutes), 62%, respectively (log-rank P=0.002). However, those with longer delays were also older and more often women. Median age rose from 66 years (interquartile range, 57-73) in the earliest quartile to 71 years (interquartile range, 62-79) in the latest quartile (P=0.005), and the proportion of women increased from 15% to 34%, respectively. Combining the 3 lowest quartiles for the time from onset of symptoms to randomization, the mAFP treatment was associated with an odds ratio of 0.51 (95% CI, 0.31-0.84), whereas the odds ratio for the highest quartile was 0.92 (95% CI, 0.38-2.22; P for interaction = 0.26).

Conclusions: In patients with ST-segment-elevation myocardial infarction complicated with cardiogenic shock, treatment with an mAFP was associated with reduced all-cause mortality, but the treatment benefit appeared to weaken with prolonged time from the onset of symptoms to randomization.

Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT01633502.

Background: Cardiac conduction disturbances remain the most frequent complication of transcatheter aortic valve replacement (TAVR), but the clinical implications of new left bundle branch block (LBBB) after TAVR remain controversial. Here, we aim to assess the impact of new LBBB after TAVR on patient outcomes in a large, real-world registry.

Methods: The study population consisted of patients in the TVT registry (Society of Thoracic Surgery and American College of Cardiology Transcatheter Valve Therapy Registry) who underwent TAVR for aortic stenosis between 2016 and 2022 and were discharged alive from the index hospitalization. Key exclusion criteria included preexisting conduction defects and a permanent pacemaker before TAVR or during the index hospitalization. Clinical outcomes were compared between patients with and without new LBBB using Cox proportional hazards models adjusted for baseline demographic, clinical, and echocardiographic variables.

Results: Among 202 533 TAVR recipients, 32 933 (16.3%) developed new LBBB after TAVR. Over the study period, there was a significant decrease in the incidence of new LBBB from 19.9% in the first quarter of 2016 to 14.4% in the third quarter of 2022. Patients with new LBBB after TAVR, compared with those without LBBB, had significantly greater 1-year all-cause mortality (adjusted hazard ratio, 1.19 [95% CI, 1.13-1.25]; P<0.001), hospital readmission (adjusted hazard ratio, 1.23 [95% CI, 1.19-1.28]; P<0.001), and new pacemaker requirement (adjusted hazard ratio, 3.50 [95% CI, 3.26-3.76]; P<0.001). Patients with new LBBB also had lower Kansas City Cardiomyopathy Questionnaire Overall Summary scores (adjusted difference, -1.7 points [95% CI, -2.1 to -1.3]; P<0.001) and left ventricular ejection fraction (adjusted difference, -2.8% [95% CI, -3.4% to -2.2%]; P<0.001).

Conclusions: New LBBB after TAVR is associated with worse 1-year outcomes, including death, rehospitalization, and permanent pacemaker, as well as worse health status and lower left ventricular ejection fraction. These findings suggest that continued efforts to limit the development of conduction disturbance after TAVR are warranted.

Background: Racial and ethnic disparities exist in postacute myocardial infarction (AMI) care. High-potency P2Y12 inhibitors use among patients with AMI who undergo percutaneous coronary intervention (PCI) carries a class I indication in the guidelines. This study aims to examine racial and ethnic differences in high-potency P2Y12 inhibitor prescription on discharge among patients with AMI undergoing PCI.

Methods: Using data from the NCDR Cath PCI registry, we identified consecutive patients with AMI who underwent PCI from April 2018 to June 2023. Likelihood of high-potency P2Y12 inhibitor prescription on discharge was assessed using logistic regression models adjusted for social deprivation index and other patient- and procedure-related variables.

Results: Among 1 662 387 patients hospitalized with AMI and who underwent PCI, 165 579 (9.9%) were Black, 58 595 (3.5%) were Asian, and 1 302 576 (78.3%) were of White race, while 135 637 (8.1%) were of Hispanic ethnicity. At discharge 876 078 (52.7%) were prescribed a high-potency P2Y12 inhibitor. Compared with White patients, Black patients were less likely (adjusted odds ratio, 0.93 [95% CI, 0.92-0.94]), while Asians were more likely (adjusted odds ratio, 1.08 [1.07-1.10]) to have a high-potency P2Y12 inhibitor discharge prescription. Compared with non-Hispanics, Hispanic patients were less likely to have a high-potency P2Y12 inhibitor discharge prescription (adjusted odds ratio, 0.95 [95% CI, 0.93-0.96).

Conclusions: In a contemporary national registry of hospitalized patients with AMI who underwent PCI, Black and Hispanic patients were less likely to be discharged on a high-potency P2Y12 inhibitor irrespective of socioeconomic status. These findings highlight an opportunity to achieve equity in guideline-directed AMI pharmacotherapies to improve outcomes.

Background: It remains unclear whether drug-coated balloons (DCBs) and drug-eluting stents are comparable in the treatment of coronary artery disease (CAD) and whether limus versus paclitaxel DCBs yield similar clinical outcomes. We aimed to assess the clinical efficacy of limus and paclitaxel DCBs in patients with CAD through a network meta-analysis.

Methods: We comprehensively searched multiple databases for randomized controlled trials comparing the following 4 strategies: limus DCB, paclitaxel DCB, second-generation or newer drug-eluting stent, and plain old balloon angioplasty. The primary outcome was trial-defined major adverse cardiovascular events (MACEs), typically a composite of death, myocardial infarction, or target lesion revascularization. Secondary outcomes included individual components of MACE. We performed subgroup analyses for in-stent restenosis, small-vessel (<3 mm) CAD, and other de novo CAD, such as large vessel and ST-segment-elevation myocardial infarction.

Results: We identified 39 randomized controlled trials including 10 219 patients. There was no significant difference in MACE between limus and paclitaxel DCBs (relative risk, 1.22 [95% CI, 0.86-1.73]). There were no significant differences in MACE between limus or paclitaxel DCB and second-generation or newer drug-eluting stents. Plain old balloon angioplasty had an increased risk of MACE compared with others. These results were consistent across subgroup analyses for in-stent restenosis, small-vessel CAD, and other de novo CAD.

Conclusions: No significant differences were observed in MACE or its components between limus and paclitaxel DCBs, albeit with limited statistical power. Furthermore, DCB and second-generation or newer drug-eluting stents yielded similar outcomes though power was limited, especially for other de novo CAD.

Registration: URL: https://www.crd.york.ac.uk/PROSPERO/; Unique identifier: CRD420250654276.