Cardiovascular Revascularization Medicine最新文献

Objective: This meta-analysis sought to investigate if IVUS-guided PCI (IVUS-PCI) can improve outcomes compared to standard PCI and CABG in patients with multivessel CAD.

Background: Coronary artery disease (CAD) is traditionally revascularized by either percutaneous coronary intervention (PCI) or coronary artery bypass (CABG) with a historical benefit of CABG over PCI in multivessel CAD. Intravascular ultrasound-guided PCI (IVUS-PCI) may improve outcomes compared to angiography alone.

Methods: We undertook a systematic search using PubMed, MEDLINE, EMBASE, Web of Science, and Ovid from 2017 through 2022. We included randomized controlled trials and observational trials comparing PCI vs CABG for multivessel CAD evaluated by two independent reviewers. We extracted baseline data and major adverse cardiovascular events (MACE; death from any cause, MI, stroke, or repeat revascularization) at one year. Three trials were selected based on study arm criteria: FAME 3, BEST, and Syntax II.

Results: IVUS-PCI significantly reduced death from any cause (OR 0.45, CI 0.272-0.733, p = 0.001), repeat revascularization (OR 0.62, CI 0.41-0.95, p = 0.03), and showed a non-significant reduction in MACE (OR 0.74, CI 0.54-1.01, p = 0.054) when compared to CABG. IVUS-PCI significantly reduced MACE (OR 0.52, CI 0.38-0.72, p < 0.001) and showed a non-significant reduction in death (OR 0.66, CI 0.36-1.18, p = 0.16) and numerically reduced repeat revascularization (OR 0.66, CI95 0.431-1.02, p = 0.06) when compared to PCI without IVUS.

Conclusion: IVUS-PCI reduces cardiovascular outcomes in patients with multivessel disease compared to CABG and angiographically-guided PCI at one year. These results reinforce the importance of IVUS-PCI in complex CAD and provide evidence for improved PCI outcomes compared to CABG for multivessel CAD.

Introduction: Dual antiplatelet therapy (DAPT) with aspirin and a P2Y₁₂ inhibitor is the standard of care for patients who undergo percutaneous coronary intervention (PCI) for ST elevation myocardial infarction (STEMI). Though this regimen reduces rates of ischemic events in patients with STEMI, the optimal strategy for P2Y₁₂ administration in STEMI patients is still evolving.

Purpose: The purpose of this review is to summarize current evidence on optimal use of ticagrelor and prasugrel in the acute phase of STEMI.

Summary: Due to high platelet activity in the acute setting of STEMI and PCI, adequate and rapid platelet inhibition is important. Strategies of increased ticagrelor/prasugrel loading dose or earlier administration in STEMI have not been successful in closing this platelet inhibition gap. Potential strategies for improving ticagrelor/prasugrel use early in STEMI include bridging with intravenous antiplatelet agents or crushed or chewed administration.

Conclusion: Oral ticagrelor/prasugrel given before or immediately after STEMI PCI is usually sufficient to prevent thrombotic complications. When faster platelet inhibition is desired, or oral administration is compromised by inability to swallow tablets, crushing/chewing ticagrelor/prasugrel tablets is an alternative to intravenous P2Y₁₂ inhibitor therapy.

Transcatheter closure of atrial septal defects (ASD) and patent foramen ovale (PFO) can be performed with transesophageal echocardiography (TEE) or intracardiac echocardiography (ICE) guidance, but data comparing both modalities in contemporary practice is lacking. Using ICD-10 codes, patients who underwent transcatheter ASD/PFO closure between 2016 and 2020 using ICE or TEE in the Nationwide Readmissions Database (NRD) were identified. Propensity-score matching was performed to compare in-hospital adverse events, length of stay (LOS), cost, and 30-day non-elective readmissions. A total of 964 patients underwent ASD/PFO closure with ICE (38.3 %, n = 369) or TEE (61.7 %, n = 595) between 2016 and 2020. Propensity score matching yielded 327 patients in each group, which were well balanced. Median (IQR) age was 59.0 (46.0, 72.0) years and 54.7 % were female. No difference was observed in the rate of in-hospital major adverse events between groups. ICE guidance was associated with a lower median cost (ICE $20,140.1 (14,622.3, 25,027.0) vs TEE $20,740.4 (14,137.5, 33,045.3), p < 0.04). In conclusion, ICE guided ASD/PFO closure was associated with lower hospitalization cost without increasing in-hospital adverse events when compared with TEE guidance.

Background: Takotsubo syndrome (TTS), a stress-induced transient left ventricular dysfunction, remains poorly understood, with an estimated incidence of 1-2 % among acute coronary syndrome cases. This study investigates racial and ethnic disparities in hospital outcomes and clinical characteristics of TTS.

Methods: We conducted a retrospective cohort study using the National Inpatient Sample data from 2016 to 2020, identifying TTS cases through validated ICD-10 codes. Statistical analysis was performed using Stata 18, with logistic regression models adjusting for confounders to identify disparities in outcomes.

Results: The study included 32,785 TTS hospitalizations; the majority were White (80.5 %), followed by Black (6.7 %) and Hispanic (5.8 %) patients. Minority groups, mainly Black and Hispanic patients, were younger (average age 63) and predominantly from lower-income brackets, while Asians had the highest income bracket. Length of stay (5.1 days) and Total cost ($22,707.60) were highest among Native Americans. Notable findings include Black patients showing the highest rate of stroke (4.8 %, OR 2.1, 95 % CI 1.2 to 3.4, p = 0.003). The rate of cardiogenic shock was highest among Asians (11 %, OR 2, 95 % CI 1.5 to 2.5, p < 0.001). Mortality rates were elevated in Black (2 %, OR 1.5, 95 % CI 1.3 to 1.7 p < 0.001) and Asian populations (1.8 %, OR 1.97, 95 % CI 1.5 to 2.5, p < 0.001).

Conclusion: Significant racial and ethnic disparities exist in TTS outcomes, with minority groups having more in-hospital outcomes. These findings highlight the urgent need for targeted interventions and further research to reduce healthcare inequities in TTS management.

Background: Cardiovascular disease remains the leading cause of death and the use of percutaneous coronary intervention (PCI) is steadily increasing. Current guidelines advocate the use of the fractional flow reserve (FFR) to assess coronary stenosis and treatment strategies; however, invasive FFR has some limitations. Angiography-derived FFR is a potential alternative for calculating FFR from two-dimensional (2D) angiographic images, thereby reducing invasiveness and complications. A novel artificial intelligence (AI)-based angiography-derived FFR, named "MPFFR," offers automated operator-independent hemodynamic calculations; this phase 3 trial aims to validate its diagnostic performance against 2D-quantitative coronary angiography (QCA).

Methods and analysis: This pivotal MPFFR trial is a prospective, multicenter, single-blind study. This trial involves patients with coronary artery disease (CAD) from eight cardiovascular centers. Invasive FFR will be performed according to standard guidelines and defined as the reference standard. Angiography-derived FFR will be computed using a proprietary method and 2D-QCA will be performed using validated software. The primary endpoint is the area under the curve for identifying physiologically significant coronary stenosis (FFR ≤0.80), with secondary endpoints including diagnostic accuracy, sensitivity, specificity, positive predictive value, negative predictive value, and correlations between angiography-derived and invasive FFR. This study is designed to demonstrate the superiority of angiography-derived FFR over 2D-QCA and is powered to achieve this with a sample size of 240 patients. Medipixel Inc. supports the trial and is not involved in the data analysis or management.

Background: Transcatheter aortic valve implantation (TAVI) is a well-established treatment for symptomatic patients with aortic stenosis. Yet, the impact of sex differences and public vs. private procedural setting on TAVI outcomes remain uncertain.

Methods: The RIBAC-NT (Brazilian Registry for Evaluation of Transcatheter Aortic Valve Replacement Outcomes) dataset included 3194 TAVI patients from 2009 to 2021. This retrospective analysis explored disparities in baseline characteristics, procedural and in-hospital outcomes stratifying patients by sex and procedural setting. Temporal trends were also investigated.

Results: We included 1551 (49 %) female and 1643 (51 %) male patients. Women were older (83 [78-87] vs. 81 [75-85] years; p < 0.01) but had a lower prevalence of diabetes mellitus (30.2 % vs. 36.3 %, p < 0.01) and coronary artery disease (39.0 % vs. 52.2 %, p < 0.01). However, women had a 3-fold higher higher risk of life-threatening bleeding (6.1 % vs. 2.4 %, p < 0.01). Women presented higher procedural and in-hospital mortality rates (4.4 % vs. 2.5 % and 7.7 % vs. 4.5 %, all p < 0.01, respectively). Although public hospitals presented ~2-fold higher procedural mortality rate compared with private settings (5.0 % vs. 2.7 %, p < 0.01), after multivariable analysis procedural setting was not independently associated with in-hospital mortality.

Conclusions: Women had higher procedural and in-hospital mortality rates after TAVI as compared with men, while facing higher life-threatening bleeding and adverse events rates. Although public hospitals exhibited higher mortality rates than private centers, procedural setting was not independently associated with in-hospital mortality.

Lately, a large number of stable ischemic patients, with no obstructed coronary arteries are being diagnosed. Despite this condition, which is being described as angina with no obstructive coronary arteries (ANOCA), was thought to be benign, recent evidence report that it is associated with increased risk for adverse cardiovascular outcomes. ANOCA is more frequent in women and, pathophysiologically, it is predominantly related with microvascular dysfunction, while other factors, such as endothelial dysfunction, inflammation and autonomic nervous system seem to also play a major role to its development, while other studies implicate ANOCA and microvascular dysfunction in the pathogenesis of heart failure with preserved ejection fraction. For establishing an ANOCA diagnosis, measurement including coronary flow reserve (CFR), microvascular resistance (IMR) and hyperemic microvascular resistance (HMR) are mostly used in clinical practice. In addition, new modalities, such as optical coherence tomography (OCT) are being tested and show promising results for future diagnostic use. Regarding management, pharmacotherapy consists of a wide selection of drugs, according to the respected pathophysiology of the disease (vasospastic angina or microvascular dysfunction), while research for new treatment options including interventional techniques, is currently ongoing. This review, therefore, aims to provide a comprehensive analysis of all aspects related to ANOCA, from pathophysiology to clinical managements, as well as clinical implications and suggestions for future research efforts, which will help advance our understanding of the syndrome and establish more, evidence-based, therapies.

Objective: To examine the characteristics and outcomes of acute myocardial infarction (AMI) in patients with bleeding and/or hypercoagulable disorders.

Background: Studies examining the outcomes of AMI in bleeding/hypercoagulable disorders are scarce.

Methods: The Nationwide Readmissions Database was utilized to identify hospitalizations with AMI from 2016 to 2020. The study cohort was divided into 4 groups: (1) MI without bleeding or hypercoagulable disorders, (2) MI with bleeding disorders, (3) MI with hypercoagulable disorders and (4) MI with mixed disorders. The main outcome was all-cause in-hospital mortality.

Results: A total of 4,206,005 weighted hospitalizations with AMI were identified during the study period, of which 382,118 (9.1 %) had underlying bleeding or hypercoagulable disorders. The utilization of invasive strategies for the management of MI was highest in patients without bleeding or hypercoagulable disorders (62.6 %) and lowest in patients with mixed disorders (39.3 %). In-hospital mortality was higher among patients with bleeding (adjusted odds ratio [OR] 1.22; 95 % confidence interval [CI] 1.21, 1.24) and mixed disorders (aOR 3.38; 95 % CI 3.27, 3.49) compared with patients without bleeding or hypercoagulable disorders. Among patients with any bleeding or hypercoagulable disorder, those who underwent invasive strategy had lower adjusted odds of in-hospital mortality (aOR 0.28; 95 % CI 0.27, 0.30), ischemic stroke (aOR 0.60; 95 % CI 0.56, 0.64), bleeding (aOR 0.63; 95 % CI 0.61, 0.65), blood transfusion (aOR 0.95; 95 % CI 0.91, 0.99) and 30-day urgent readmissions (aOR 0.70; 95 % CI 0.68, 0.72).

Conclusions: The inpatient management and outcomes of AMI in patients with bleeding/hypercoagulable disorders differ from patients without those disorders. Revascularization in the setting of AMI was associated with lower in-hospital mortality, which suggests that patients with bleeding/hypercoagulable disorders can be evaluated for standard approaches to managing AMI; however, confounding by indication may be a concern.

Introduction: Coronary artery bypass graft surgery has considerable effects on patient haemostasis. Heparins as thromboprophylaxis may be beneficial but may also increase the risk of bleeding complications.

Objectives: To assess the effects of heparins on haemostasis in post-coronary artery bypass graft patients.

Methods: Across one year, we randomised 60 participants scheduled for an elective coronary artery bypass graft-procedure with or without aortic valve replacement. The trial was a prospective, open-label (though blinded for the laboratory), randomised, single-centre trial with three intervention groups (n = 20 in each): group 1 received acetylsalicylic acid, group 2 received subcutaneous low molecular weight heparin and acetylsalicylic acid, and group 3 received intravenous unfractionated heparin and acetylsalicylic acid. Primary outcomes were platelet activation (Multiplate® ASPI-test) and time to clot initiation (TEG® R-time). We secondly assessed several additional Multiplate® and TEG® parameters.

Results: Group 3 (intravenous unfractionated heparin) compared with group 1 (acetylsalicylic acid alone) showed evidence of 1) increased clot initiation time (R-time + 0.9 min; 95 % CI: +0.4 to +1.4 min; P = 0.009), and 2) decreased 30-min lysis (-1.3 %; 95 % CI: -2.1 to -0.5 %; P = 0.02). The remaining analyses of primary and secondary outcomes showed no evidence of a difference between the three groups.

Discussion: Intravenous unfractionated heparins may increase the clot initiation time post-operatively after coronary artery bypass graft surgery and reduce lysis. Otherwise, there seems to be no effect of low molecular weight or unfractionated heparin on haemostatic parameters after coronary artery bypass surgery patients.

Background: Anomalous coronary arteries (ACA) are seen in 1-5 % of patients undergoing coronary angiography, and their presence may increase procedural difficulty. We aimed to compare procedural outcomes of coronary angiography in ACA patients by anatomy and prior knowledge of the ACA.

Methods: This was a single-center review of ACA patients undergoing coronary angiography between October 2013 and February 2022. Primary endpoints were contrast volume, fluoroscopy dose, time, and dose-area product (DAP). Comparisons were made between groups based on ACA anatomy and based on prior knowledge of the ACA.

Results: We found 176 diagnostic coronary angiograms among ACA patients. Anomalies of the right coronary artery (RCA) comprised 77 %, followed by left circumflex (LCX) at 16 % and left main or left anterior descending (LMCA/LAD) at 7 %. There was significantly more contrast use among patients with RCA (mean 110.5 mL) or LMCA/LAD (115.6 mL) anomalies than LCX (76.2 mL; p = 0.01). There was no difference in fluoroscopy dose, time, or DAP. Prior knowledge of the anomaly was recorded in 61 (35 %) cases. Contrast volume (mean difference 27.1 mL, 95 % confidence interval: 12.5-41.8) and all fluoroscopy measures decreased if the ACA was previously known to the operators.

Conclusion: Different types of ACAs are associated with increased contrast use but not fluoroscopy exposure. Prior knowledge of ACA is associated with decreased contrast use and fluoroscopy exposure. Thorough review of prior catheterizations and knowledge of catheter selection is important for reducing contrast use and fluoroscopy exposure in patients with ACA.