Cardiovascular Revascularization Medicine最新文献

Background: There exists clinical equipoise regarding whether and when an invasive approach should be preferred over conservative treatment in the management of stable late ST-elevation myocardial infarction (STEMI) presenting within 12 to 72 h of symptom onset.

Objective: To perform a systematic review to identify the most effective treatment strategy between percutaneous coronary intervention (PCI) and medical therapy in stable late STEMI presenters by comparing their respective outcomes as well as determine the optimal timing of PCI by evaluating the outcomes of urgent versus non-urgent PCI approach in this patient population.

Methods: PubMed, Embase, and Cochrane databases were queried from inception until March 2024 for studies comparing the outcomes of PCI versus medical therapy, as well as urgent versus non-urgent PCI, in stable late STEMI patients presenting with symptom onset within 12-72 h. Quality of the studies and risk of bias were assessed using the Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) criteria and the Cochrane Risk of Bias (ROBINS-I 2016) tool, respectively.

Results: A total of 8 studies were included in this systematic review that met the inclusion criteria. Among these, 5 studies (1 randomized controlled trial (RCT), 1 post-hoc analysis, and 3 observational studies) with an aggregate of 3820 participants compared PCI and medical therapy in stable late STEMI presenters. They found that PCI was associated with statistically significant better short- and long-term outcomes by lowering all-cause mortality, recurrent myocardial infarction (MI), and infarct size, and by improving myocardial salvage index (P < 0.001). Similarly, a non-statistically significant improvement was seen in the events of cardiac death, heart failure, and revascularization as well as ejection fraction percentage with PCI (P > 0.05). The other 3 studies, involving 1270 participants, were observational and compared urgent versus non-urgent PCI and did not find any statistically significant difference in clinical outcomes between the two approaches (P > 0.05). The included studies were significantly heterogeneous in methodologies, follow-up intervals, and reporting of outcomes. Most of the studies provided moderate quality of evidence and had moderate to serious risk of bias.

Conclusions and relevance: Revascularization through PCI is associated with superior short- and long-term outcomes compared to medical therapy in stable late STEMI patients presenting within 12-72 h of symptom onset. However, the optimal timing of PCI needs further investigation.

Introduction: Older patients may be denied endovascular revascularization of the superficial femoral artery (SFA) for peripheral artery disease (PAD) due to concerns of worse limb outcomes than younger patients.

Methods: We assessed adverse outcomes in patients after an index revascularization stratified by age (age < 65, 65-75 years, and > 75 years) from two centers between 2003 and 2011 and followed a median 9 (25 %-75 %: 7, 11) years. Outcomes included major adverse limb events (MALE) or minor repeat revascularization, death, and major adverse cardiac and cerebrovascular events (MACCE). We used cause-specific and competing-risks analyses with clustering by patient to determine the hazard ratios (HR), sub-hazard ratios (SHR), 95 % confidence intervals (95%CI) for outcomes according to older age.

Results: There were 253 limbs revascularized in 202 patients with a high use of lipid lowering therapy (91 %) and aspirin anti-platelet therapy (96 %). In oldest age group (>75 years), 71 limbs were revascularized and patients were less likely to be active smokers and had poorer tibial runoff than younger patients. In competing risks multivariable models, patients >75 years old had similar risks over 10 years of MALE or minor revascularization (SHR = 0.92, 95%CI = 0.53, 1.62) and MACCE (SHR = 1.12, 95%CI = 0.58, 2.18) to younger patients. All-cause death was more common in older patients (HR = 1.99, 95%CI = 1.25, 3.17).

Conclusions: After adjusting for the competing risk of death, patients >75 years had similar incidence of adverse limb outcomes and MACCE to younger patients after endovascular revascularization of the femoral artery. Consequently, older patients should be considered for endovascular revascularization when indicated.

In this review article, we provide an overview of the definition and application of fractional flow reserve (FFR), instantaneous wave-free ratio (iFR), coronary flow reserve (CFR), and index of microvascular resistance (IMR) in the diagnosis, prognosis, and management of coronary microvascular dysfunction. We discuss their respective limitations as it relates to microvascular dysfunction. In each section, we review the most recent evidence supporting their use in microvascular and epicardial coronary artery disease. We also highlight specific clinical conditions with emerging indications for the use of these indices, including in the setting of microvascular dysfunction due to acute myocardial infarction, heart failure with preserved ejection fraction, and post-cardiac transplant.

Background: The prognostic implications of cerebral microbleeds (CMBs) in patients who undergo transcatheter aortic valve replacement (TAVR) have not been fully elucidated. Therefore, we aimed to investigate the association between the presence of CMBs and adverse outcomes post-TAVR.

Methods: In this single-center retrospective study, we included 124 patients who underwent brain magnetic resonance imaging before TAVR. The outcomes of interest were the subsequent incidences of stroke and all-cause death or admission for heart failure.

Results: CMBs were identified in 32.2 % of the included patients. The median follow-up duration was 954 (interquartile range, 553-1306) days. The incidence of stroke after TAVR was comparable between patients with and without CMBs. Conversely, all-cause death or admission for heart failure was significantly higher in patients with CMBs than in those without (log-rank P = 0.010). Multivariate Cox regression analysis revealed that the presence of CMBs was independently correlated with the occurrence of all-cause death or admission for heart failure after adjusting for other prognostic predictors (hazard ratio 4.016, 95 % confidence interval 1.572-10.259, P = 0.007).

Conclusion: The presence of CMBs predicts the incidence of all-cause death or admission for heart failure in patients undergoing TAVR. Evaluating CMBs could provide useful information for post-TAVR management.

Background: There is uncertainty about the use of the CHA2DS2-VASc score to predict clinical events in patients with Takotsubo syndrome (TTS). This study aimed to assess the short-term prognostic role of CHA2DS2-VASc score in this population.

Methods: All admissions with a primary diagnosis of TTS were included using data from the National Inpatient Sample database during 2016-2019. The primary outcome was in-hospital mortality and secondary outcomes included ischemic stroke, intracardiac thrombus, cardiogenic shock, requirement for mechanical circulatory support, and renal replacement therapy. Patients were divided into 3 groups according to the CHA2DS2-VASc score. (0-3, 4-6, and >6). Logistic regression was used to estimate odds ratios (OR) with 95 % confidence intervals (CI).

Results: A total 32,595 weighted hospitalizations were included (median age was 67 [58-76] years; 90 % female). The median CHA2DS2-VASc score value was 4 (2-5). In the adjusted models, in-hospital mortality was significantly higher in the CHA2DS2-VASc 4-6 (OR 1.86, 95 % CI 1.09-3.16, p = 0.022) and CHA2DS2-VASc >6 (OR 3.35, 95 % CI 1.60-7.04, p = 0.001) groups compared to the CHA2DS2-VASc 0-3 group. Likewise, the CHA2DS2-VASc >6 group had significantly higher odds of ischemic stroke (OR 2.92, 95 % CI 1.22-6.96, p = 0.016), intracardiac thrombus (OR 3.56, 95 % CI 1.36-9.30, p = 0.010), cardiogenic shock (OR 1.73, 95 % CI 1.05-2.86, =0.033), and renal replacement therapy (OR 2.87, 95 % CI 1.04-7.92, p = 0.042).

Conclusions: Our results suggest that the CHA2DS2-VASc score is relatively useful for predicting in-hospital mortality and a range of clinical events in hospitalized patients with TTS.