Coronary artery disease最新文献

Background: Calcified nodules (CNs) are an advanced stage of coronary calcification that can have significant clinical implications. We investigated factors associated with CNs, the etiology of which is not fully understood.

Methods: We retrospectively evaluated 619 patients with stable coronary artery disease who underwent intravascular ultrasound (IVUS)-guided percutaneous coronary intervention (PCI). CNs in the culprit lesion were evaluated via IVUS, and all-cause mortality and major cardiovascular and cerebrovascular events (MACCEs) were compared between the CN and non-CN groups.

Results: The CN group ( n  = 40 patients) had a significantly lower survival rate and a higher incidence of MACCE than the non-CN group ( P  = 0.020 and P  < 0.001, respectively). Multivariate logistic regression analysis models revealed that chronic kidney disease and serum cholinesterase (ChE) level were associated with CN formation [odds ratio (OR): 3.15, 95% confidence interval (CI): 1.30-7.69, P  = 0.001 and OR: 0.94, 95% CI: 0.88-0.99, P  = 0.042]. The optimal cutoff of serum ChE level as per the receiver operating characteristic curve was 309 units/l (Area under the curve = 0.67, sensitivity = 93%, specificity = 40%, P  = 0.001). The low-ChE group divided according to the optimal cutoff value showed significantly higher cumulative incidence of MACCEs after PCI than the high-ChE group as per Kaplan-Meier analysis.

Conclusion: The presence of CNs is significantly associated with a poor prognosis and MACCE after PCI among patients with stable coronary artery disease. Serum ChE levels may affect CN formation.

Background: Recent guidelines on acute coronary syndromes (ACS) recommend initiating lipid-lowering therapy (LLT) as early as possible to obtain >50% low-density-lipoprotein cholesterol (LDL-c) reduction and an LDL-c < 1.4 mmol/l.

Methods: A multinational European survey study of ACS patients between 2021-2022 and acquired data on LLT and lipid levels on admission and during 1-year posthospitalization. We compared plasma lipid changes and adherence to post-ACS lipid targets across two in-hospital LLT groups: high-intensity statin (HIS) monotherapy (mono-HIS) and a combination of HIS and ezetimibe (combo-HIS).

Results: Of 286 patients, 268 (94%) received in-hospital HIS and were included in the final analysis. Patients (median age: 61.1 years) had a median baseline LDL-c of 3.3 mmol/l. Mono-HIS was the predominant in-hospital LLT (72.4%). In-hospital combo-HIS was administered in 27.6% of the cases. Patients from high-income countries ( n  = 141) were more likely to receive in-hospital combo-HIS than patients from middle-income countries [ n  = 127; 38.3% vs. 15.7% patients, P  < 0.001). One-year post-ACS, 50 (26.5%) patients from the mono-HIS group received ezetimibe. The target of LDL-c ≤ 55 mg/dl was reached in 85 patients (31.7%), without significant difference between study groups [mono-HIS: 56 (28.9%) and combo-HIS: 29 (39.2%) patients, P  = 0.10]. The target of >50% reduction was achieved more frequently among the combo-HIS group than in the mono-HIS group (50.0% vs. 29.9%, respectively, P  = 0.002).

Conclusion: LDL-c targets were achieved in less than half of the patients post-ACS, regardless of the LLT regimen. Combo-HIS was initiated in-hospital post-ACS in only 28% and was associated with greater LDL-c reduction compared to a staged approach of mono-HIS with up-titration at follow-up.

Background: Distal radial access (DRA) is a well-tolerated and effective alternative to traditional radial access (TRA) for coronary procedures. However, the comparative value of these modalities remains unknown in the emergency setting, particularly in patients with ST-elevation myocardial infarction (STEMI).

Objective: To compare DRA versus TRA for emergency coronary procedures through a meta-analysis.

Methods: We systematically searched PubMed , Embase , and Cochrane databases to identify studies comparing DRA versus TRA in patients undergoing emergency coronary angiography (CAG) or percutaneous coronary intervention (PCI). All statistical analyses were performed using R software version 4.3.1 with a random-effects model.

Results: We included four studies comprising 543 patients undergoing emergency CAG or PCI, of whom 447 (82.3%) had STEMI. As compared with TRA, DRA was associated with lower radial artery occlusion rates (RR, 0.21; 95% CI, 0.06-0.72) and shorter hemostasis time (MD, -4.23 h; 95% CI, -6.23 to 2.13). There was no significant difference between modalities in terms of puncture failure (RR, 1.38; 95% CI, 0.31-6.19), crossover access (RR, 1.37; 95% CI, 0.42-4.44), puncture time (SMD, 0.33; 95% CI, -0.16 to 0.81), procedure time (MD, 0.97 min; 95% CI, -5.19 to 7.13), or rates of cannulation success (RR, 0.94; 95% CI, 0.83-1.06). In terms of other periprocedural complications, there were no differences between both groups. These findings remained consistent in a subgroup analysis of patients with STEMI.

Conclusion: In this meta-analysis, DRA was superior to TRA in terms of radial artery occlusion and hemostasis time, with similar rates of periprocedural complications.

Background: The efficacy of adding ezetimibe to statin therapy for event reduction in patients with acute coronary syndromes (ACS) remains a topic of ongoing debate.

Methods: We performed a systematic review and meta-analysis of randomized controlled trials (RCTs) comparing ezetimibe plus statin versus statin monotherapy in patients with ACS. We searched PubMed, Embase, and Cochrane for eligible trials. The random-effects model was used to calculate the risk ratios with 95% confidence intervals (CIs). Statistical analyses were performed using RStudio version 4.2.3 (RStudio, PBC).

Results: Six RCTs comprising 20 574 patients with ACS were included, of whom 10 259 (49.9%) were prescribed ezetimibe plus statin. The patient population had an average age of 63.8 years, and 75.1% were male. Compared with statin monotherapy, ezetimibe plus statin significantly reduced major adverse cardiovascular events (MACE) (risk ratio 0.93; 95% CI 0.90-0.97; P  < 0.01) and nonfatal myocardial infarction (risk ratio 0.88; 95% CI 0.81-0.95; P  < 0.01). There was no significant difference between groups for revascularization (risk ratio 0.94; 95% CI 0.90-1.00; P  = 0.03), all-cause mortality (risk ratio 0.87; 95% CI 0.63-1.21; P  = 0.42), or unstable angina (risk ratio 1.05; 95% CI 0.86-1.27; P  = 0.64).

Conclusion: In this meta-analysis of patients with ACS, the combination of ezetimibe plus statin was associated with a reduction in MACE and nonfatal myocardial infarction, compared with statin monotherapy.

Background: Smoking is a known risk for sudden cardiac death (SCD) in the general population. However, its significance in patients with acute coronary syndrome (ACS), a condition that also elevates the risk of SCD, is disputable.

Methods: A total of 9704 consecutive ACS patients with available smoking data were included in the analysis. Comprehensive patient data were obtained from the Mass Data in Detection and Prevention of Serious Adverse Events in Cardiovascular Disease research database. A composite endpoint of SCD, SCD aborted by successful resuscitation and accurate implantable cardioverter defibrillator therapy to otherwise potentially fatal ventricular fibrillation/ventricular tachycardia was used. Univariate, age- and sex-adjusted, and a multivariate fine-gray competing risk regression with adjustment to traditional risk factors was conducted.

Results: Median follow-up time was 6.8 years (IQR, 4.1-10.2), and 454 (4.7%) SCD cases were identified. At the baseline, 23.7% ( N  = 2444) were active smokers, and 20.8% ( N  = 2146) were ex-smokers. In the multivariate model, active smokers had an elevated risk of 1.79 (95% CI, 1.41-2.27; P  < 0.001) for future SCD. Ex-smokers had no elevated risk for SCD in fine-gray subdistribution hazard. Also, active smokers were notably younger (mean age 58.7 years) than non- or ex-smokers (71.1 years and 68.9 years, respectively, P  < 0.001 for both comparisons).

Conclusion: Active smokers had a 79% higher risk of SCD when compared with nonsmokers. Smoking cessation should be heavily encouraged after ACS. Also, a person's smoking status should be considered in further studies developing SCD and implantable cardioverter defibrillator-benefit risk scores.

Background: Unfractionated heparin (UFH) is frequently administered before percutaneous coronary intervention in patients with ST segment elevation myocardial infarction (STEMI). Current guidelines, however, do not provide clear recommendations for UFH pretreatment before arrival at the coronary catheterization laboratory.

Methods: Between June and July 2023, we systematically searched PubMed , Embase , and Cochrane databases for studies comparing UFH pretreatments in patients with STEMI. A random-effects meta-analysis and meta-regression analyses were performed.

Results: Fourteen studies were included, of which four were randomized clinical trials. A total of 76 446 patients were included: 31 238 in the pretreatment group and 39 208 in the control group. Our meta-analysis revealed lower all-cause mortality for the pretreatment strategy when compared with the control group, albeit with high heterogeneity [pooled odds ratio (OR) = 0.61, 95% confidence interval (CI): 0.49-0.76, P  < 0.01; I2  = 77%]; lower in-hospital cardiogenic shock (pooled OR = 0.68, 95% CI: 0.58-0.78, P  < 0.21; I2  = 27%) and a higher rate of spontaneous reperfusion events (pooled OR = 1.68, 95% CI: 1.47-1.91, P  < 0.01; I2  = 79%). In terms of major bleeding, the UFH pretreatment strategy further revealed a decreased rate of events (pooled OR = 0.85, 95% CI: 0.73-0.99, P  = 0.40; I2  = 4%).

Conclusion: Our study suggests that UFH pretreatment in patients with STEMI undergoing primary percutaneous coronary intervention was associated with reduced all-cause mortality, cardiogenic shock, enhancing reperfusion rates while diminishing major bleeding events.

Background: Previous reports have suggested that coronary computed tomography angiography (CCTA)-based radiomics analysis is a potentially helpful tool for assessing vulnerable plaques. We aimed to investigate whether coronary radiomic analysis of CCTA images could identify vulnerable plaques in patients with stable angina pectoris.

Methods: This retrospective study included patients initially diagnosed with stable angina pectoris. Patients were randomly divided into either the training or test dataset at an 8 : 2 ratio. Radiomics features were extracted from CCTA images. Radiomics models for predicting vulnerable plaques were developed using the support vector machine (SVM) algorithm. The model performance was assessed using the area under the curve (AUC); the accuracy, sensitivity, and specificity were calculated to compare the diagnostic performance using the two cohorts.

Results: A total of 158 patients were included in the analysis. The SVM radiomics model performed well in predicting vulnerable plaques, with AUC values of 0.977 and 0.875 for the training and test cohorts, respectively. With optimal cutoff values, the radiomics model showed accuracies of 0.91 and 0.882 in the training and test cohorts, respectively.

Conclusion: Although further larger population studies are necessary, this novel CCTA radiomics model may identify vulnerable plaques in patients with stable angina pectoris.

Background: Distal radial access (DRA) through the anatomical snuff-box is a novel technique for coronary procedures. Emerging evidence suggests that DRA is associated with a lower risk of certain complications compared to proximal radial access (PRA).

Methods: A systematic review was conducted to compare clinical and procedural outcomes between both access sites for coronary angiography and percutaneous coronary intervention. We searched PubMed, Web of Science, Cochrane, and Scopus to identify relevant randomized controlled trials.

Results: We included 23 randomized controlled trials enrolling 10 062 patients (DRA group: 5042; PRA group: 5020) in this review. DRA was associated with a lower risk for radial artery occlusion (RAO) at the longest reported follow-up [risk ratio (RR): 0.30, P < 0.00001], in-hospital RAO (RR: 0.28, P < 0.00001), any bleeding (RR: 0.40, P = 0.04), hand clumsiness (RR: 0.05, P < 0.00001), and shorter time to hemostasis [mean difference (MD): -40.93, P < 0.00001]. However, DRA showed a higher access failure rate (RR = 2.64, P < 0.00001), longer access time (MD = 0.77, P < 0.00001), more puncture attempts (MD: 0.60, P < 0.0001), and greater access-related pain [standardized mean difference (SMD) = 0.23, P = 0.02]. Both approaches were comparable in terms of major adverse cardiac events (RR = 0.74, P = 0.60), and hand function (SMD = -0.05, P = 0.68).

Conclusion: DRA is a safe alternative to PRA for coronary procedures, with a lower risk of complications, including RAO. However, it is limited by access-related challenges.