Optimal strategy of coronary revascularization in chronic kidney disease patients: A meta-analysis

BackgroundPatients with chronic kidney disease (CKD) have high risks of coronary artery disease (CAD). Coronary revascularization is beneficial for long-term survival, but the optimal strategy remains still controversial.MethodsWe searched studies that have compared percutaneous coronary intervention (PCI) and coronary artery bypass graft (CABG) for revascularization of the coronary arteries in CKD patients. Short-term (30 days or in-hospital) mortality, long-term (at least 12 months) all-cause mortality, cardiac mortality and the incidence of late myocardial infarction and recurrence of revascularization were estimated.Results28 studies with 38,740 patients were included. All were retrospective studies from 1977 to 2012. Meta-analysis showed that PCI group had lower short-term mortality (OR 0.55, 95% CI 0.41 to 0.73, P < 0.01), but had higher long-term all-cause mortality (OR 1.29, 95% CI 1.23 to 1.35, P < 0.01). Higher cardiac mortality (OR 1.08, 95% CI 1.01 to 1.15, P < 0.05), higher incidence of late myocardial infarction (OR 1.78, 95% CI 1.65 to 1.91, P < 0.01) and recurring revascularization rate (OR 2.94, 95%CI 2.15 to 4.01, P < 0.01) is found amongst PCI treated patients compared to CABG group.ConclusionsCKD patients with CAD received CABG had higher risk of short-term mortality but lower risks of long-term all-cause mortality, cardiac mortality and late myocardial infarction compared to PCI. This could be due to less probable repeated revascularization.     

Meta-analysis of 14 trials comparing bypass grafting vs drug-eluting stents in diabetic patients with multivessel coronary artery disease

Background and aimClinical trials have reported lower mortality and repeated revascularization rate in diabetic patients treated with coronary artery bypass grafting (CABG) as compared to percutaneous revascularization. However, these studies were conducted in the era of bare-metal stents. Therefore, we performed a meta-analysis to compare CABG to PCI with drug-eluting stents (DES) in diabetic patients with multivessel and/or left main disease.Methods and resultsThe literature was scanned by formal search of electronic databases (Medline, EMBASE, and Cochrane databases), and major international scientific session abstracts from 2000 to 2013. Primary endpoint was mortality. A total of 14 (4 randomized and 10 non-randomized) trials were finally included, with a total of 7072 patients. Up to 5 years follow-up, CABG was associated with a reduction in mortality (7.3% vs 10.4%, OR[95%CI] = 0.65[0.55–0.77], p < 0.0001; phet = 0.00001), with similar results in both RCTs (OR[95%CI] = 0.64[0.50–0.82], p = 0.0005) and NRCTs (OR[95%CI] = 0.75[0.6–0.94)], p = 0.01) (p int = 0.93). A significant relationship was observed between risk profile and benefits in mortality with CABG (p < 0.001). CABG reduced target vessel revascularization (TVR; 5.2% vs 15.7%, OR[95%CI] = 0.30[0.25–0.36], p < 0.00001, p het = 0.02), with a relationship between risk profile and the benefits from CABG as compared to DES (p < 0.0001). CABG was associated with a lower rate of MACCE (14.9% vs 22.9%, OR[95%CI] = 0.59[0.51–0.67], p < 0.00001, p het<0.00001) but higher risk of CVA (3.6% vs 1.4%, OR[95%CI] = 2.34[1.63–3.35], p < 0.00001, p het = 0.71).ConclusionsThe present meta-analysis demonstrates that among diabetic patients with multivessel disease and/or left main disease, CABG provides benefits in mortality and TVR, especially in high-risk patients but it is counterbalanced by a higher risk of stroke. Future trials are certainly needed in the era of new DES and improved antiplatelet therapies.     

Multi-vessel versus culprit-vessel and staged percutaneous coronary intervention in STEMI patients with multivessel disease: a meta-analysis of randomized controlled trials

IntroductionPercutaneous coronary intervention (PCI) is preferred in patients with acute ST-elevation myocardial infarction (STEMI). In patients with acute STEMI with multivessel disease (MVD), the guidelines recommend culprit vessel PCI (CV-PCI) in the absence of hemodynamic instability. We performed a meta-analysis of all randomized controlled trials (RCTs) comparing multi-vessel PCI (MV-PCI) with CV-PCI or staged PCI (S-PCI) in patients with acute STEMI and MVD.MethodsPubMed, EMBASE and CENTRAL were searched for publications since inception to December 2013. Random effects model was used to compute summary effects.ResultsFour RCTs (840 patients) were identified. MV-PCI compared to CV-PCI significantly reduced the risks of major adverse cardiac events (MACE)—a composite of MI, revascularization and all-cause mortality (RR: 0.46, 95% CI: 0.35–0.60, P < 0.00001) by reducing the risks of MI (0.35, 0.17–0.71, P = 0.004) and revascularization (0.35, 0.24–0.52, P < 0.00001). The risk of all-cause mortality was not different (0.69, 0.39–1.21, P = 0.19). S-PCI and MV-PCI had similar risks of MACE (0.96, 0.59–1.57, P = 0.87), MI (0.60, 0.20–1.78, P = 0.36), revascularization (0.86, 0.47–1.54, P = 0.60) and all-cause mortality (1.50, 0.44–5.07, P = 0.57).ConclusionsMV-PCI compared to CV-PCI resulted in lower risks of MACE driven by lower MI and revascularization in patients with STEMI and multi-vessel disease.     

Long-Term Outcomes of Left Main Coronary Artery Disease Treated With Drug-Eluting Stents vs Coronary Artery Bypass Grafting: A Meta-Analysis and Systematic Review

BackgroundCurrently, DES is a reasonable treatment option for LMCA disease but CABG continues to be first-line treatment. Multiple randomized clinical trials (RCTs) have compared outcomes between these two treatment modalities. Recently, these trials published their long-term results with conflicting findings.MethodsWe conducted a systematic review and meta-analysis of RCTs that compared DES vs CABG in patients with LMCA disease. We only included trials with follow up duration of at least 5 years. The primary outcome was all-cause mortality. Secondary outcomes included risk of cardiac death, myocardial infarction (MI), stroke and repeat revascularization.ResultsWe included a total of 4 RCTs. The median-weighted follow up period was 6.5 years. There was no significant difference between DES and CABG in all-cause mortality (Risk ratio (RR) 1.10; 95% confidence interval (CI) 0.92 to 1.31; p = 0.28), risk of cardiac death (RR of 1.08, 95% CI 0.84 to 1.38; p = 0.56), total MI (RR of 1.22, 95% CI 0.96 to 1.56; p = 0.11), and stroke (RR of 0.85, 95% CI 0.46 to 1.57; p = 0.60). The risk of repeat revascularization (RR of 1.75, 95% CI 1.50 to 2.03; p < 0.00001), and non-periprocedural MI (RR of 2.13, 95% CI 1.53 to 2.97; p < 0.00001) were significantly higher in the DES arm.ConclusionsDES has similar long-term outcomes compared to CABG in terms of all-cause mortality, cardiac death, total MI and stroke; but was associated with a higher risk of repeat revascularization, and non-periprocedural MI.     

Prognostic impact of concurrence of metabolic syndrome and chronic kidney disease in patients undergoing coronary intervention: Involvement of coronary plaque composition

Background and purposeMetabolic syndrome (MetS) and chronic kidney disease (CKD) have both been reported as risk factors for cardiovascular events. The aim of this study was to assess the synergistic effect of MetS and CKD on atherosclerotic plaque and cardiovascular outcomes.Methods and subjectsA total of 545 consecutive patients who underwent percutaneous coronary intervention (PCI) were divided into 4 groups based on the presence or absence of MetS and CKD. MetS was defined using the criteria of the Adult Treatment Panel III of the US National Cholesterol Education Program. CKD was defined as an estimated glomerular filtration rate of <60 ml/min/1.73 m². We analyzed the incidence of major adverse cardiac events (MACE), including cardiovascular death, nonfatal myocardial infarction, target lesion revascularization, and revascularization for new lesions. We also assessed coronary plaque characteristics of 204 patients using integrated backscatter intravascular ultrasound (IB-IVUS).ResultsMACE occurred more frequently in patients with both MetS and CKD (51.4%) than in the other groups, during the follow-up period (log-rank p < 0.001). In the IB-IVUS analyses, patients with both MetS and CKD exhibited greater plaque burden (p = 0.003) with higher lipid content (p = 0.048) compared to the other groups. In Cox analysis, both MetS and CKD proved to be independent predictors of MACE even after adjustment for confounding factors (p = 0.018).ConclusionsComorbidity of MetS and CKD is an independent predictor of adverse cardiovascular outcomes in patients undergoing coronary intervention, an effect that may be attributed to coronary plaque instability.     

Short- and Long-Term Outcomes in Patients With New-Onset Persistent Left Bundle Branch Block After Transcatheter Aortic Valve Replacement

BackgroundThe impact of new-onset persistent left bundle branch block (LBBB) after transcatheter aortic valve replacement (TAVR) on all-cause mortality has been controversial.MethodsWe conducted a systematic review and meta-analysis of eleven studies (7398 patients) comparing the short- and long- outcomes in patients who had new-onset LBBB after TAVR vs. those who did not.ResultsDuring a mean follow-up of 20.5 ± 14 months, patients who had new-onset persistent LBBB after TAVR had a higher incidence of all-cause mortality (29.7% vs. 23.6%; OR 1.28 (1.04–1.58), p = 0.02), rehospitalization for heart failure (HF) (19.5% vs. 17.3%; OR 1.4 (1.13–1.73), p = 0.002), and permanent pacemaker implantation (PPMi) (19.7% vs. 7.1%; OR 2.4 (1.64–3.52), p < 0.001) compared with those who did not. Five studies (4180 patients) reported adjusted hazard ratios (HR) for all-cause mortality; new LBBB remained associated with a higher risk of mortality (adjusted HR 1.43 (1.08–1.9), p < 0.01, I² = 81%).ConclusionPost-TAVR persistent LBBB is associated with higher PPMi, HF hospitalizations, and all-cause mortality. While efforts to identify patients who need post-procedural PPMi are warranted, more studies are required to evaluate the best follow-up and treatment strategies, including the type of pacing device if required, to improve long-term outcomes in these patients.     

Prolonged effectiveness of coronary artery bypass surgery versus drug-eluting stents in diabetics with multi-vessel disease: An updated systematic review and meta-analysis

Background

Currently, the appropriateness of percutaneous coronary intervention (PCI) using drug-eluting stents (DES) versus coronary artery bypass grafting (CABG) for patients with diabetes (DM) and multi-vessel disease (MVD) is uncertain due to limited evidence from few randomised controlled trials (RCTs). We aimed to compare the clinical effectiveness of CABG versus PCI-DES in DM-MVD patients using an evidence-based approach.

Methods

A systematic review and meta-analyses were conducted to compare the risk of all-cause mortality, myocardial infarction (MI), repeat revascularisation, cerebrovascular events (CVE), and major adverse cardiac or cerebrovascular events (MACCE).

Results

A total of 1,837 and 3,052 DM-MVD patients were pooled from four RCTs (FREEDOM, SYNTAX, VA CARDS, and CARDia) and five non-randomised studies. At mean follow-up of 3 years, CABG compared with PCI-DES was associated with a lower risk of all-cause mortality and MI in RCTs. By contrast, no significant differences were observed in the mean 3.5-year risk of all-cause mortality and MI in non-randomised trials. However, the risk of repeat revascularisations following PCI-DES compared with CABG was 2.3 (95% CI = 1.8–2.8) and 3.0 (2.3–4.2)-folds higher in RCTs and non-randomised trials, respectively. Accordingly, the risk of MACCE at 3 years following CABG compared with PCI-DES was lower in both RCTs and non-randomised trials [0.65 (: 0.55–0.77); and 0.77 (0.60–0.98), respectively].

Conclusions

Based on our pooled results, we recommend CABG compared with PCI-DES for patients with DM-MVD. Although non-randomised trials suggest no additional survival-, MI-, and CVE- benefit from CABG over PCI-DES, these results should be interpreted with care.     

Resultados intrahospitalarios tras tratamiento percutáneo frente a quirúrgico en pacientes con estenosis aórtica y enfermedad arterial coronaria concomitante

Introduction and objectivesConcomitant coronary artery disease (CAD) is prevalent among aortic stenosis patients; however the optimal therapeutic strategy remains debated. We investigated periprocedural outcomes among patients undergoing transcatheter aortic valve implantation with percutaneous coronary intervention (TAVI/PCI) vs surgical aortic valve replacement with coronary artery bypass grafting (SAVR/CABG) for aortic stenosis with CAD.MethodsUsing discharge data from the Spanish National Health System, we identified 6194 patients (5217 SAVR/CABG and 977 TAVI/PCI) between 2016 and 2019. Propensity score matching was adjusted for baseline characteristics. The primary outcome was in-hospital all-cause mortality. Secondary outcomes were in-hospital complications and 30-day cardiovascular readmission.ResultsMatching resulted in 774 pairs. In-hospital all-cause mortality was more common in the SAVR/CABG group (3.4% vs 9.4%, P < .001) as was periprocedural stroke (0.9% vs 2.2%; P = .004), acute kidney injury (4.3% vs 16.0%, P < .001), blood transfusion (9.6% vs 21.1%, P < .001), and hospital-acquired pneumonia (0.1% vs 1.7%, P = .001). Permanent pacemaker implantation was higher for matched TAVI/PCI (12.0% vs 5.7%, P < .001). Lower volume centers (< 130 procedures/y) had higher in-hospital all-cause mortality for both procedures: TAVI/PCI (3.6% vs 2.9%, P < .001) and SAVR/CABG (8.3 vs 6.8%, P < .001). Thirty-day cardiovascular readmission did not differ between groups.ConclusionsIn this large contemporary nationwide study, percutaneous management of aortic stenosis and CAD with TAVI/PCI had lower in-hospital mortality and morbidity than surgical intervention. Higher volume centers had less in-hospital mortality in both groups. Dedicated national high-volume heart centers warrant further investigation.     

Outcomes of dementia: Systematic review and meta-analysis of hospital administrative database studies

IntroductionAim of the study was to compare various outcomes of dementia patients with elderly patients without dementia by conducting a systematic review of previous population-based studies.MethodsThe relevant studies were retrieved from search of electronic databases.ResultsThe pooled data from included 11 studies consisted of outcomes of 1,044,131 dementia patients compared to 9,639,027 elderly patients without dementia. Meta-analysis showed that the mortality in dementia patients was 15.3% as compared to 8.7% in non-dementia cases (RR 1.70, CI 95%, 1.27-2.28, p 0.0004). However, there was significant heterogeneity between the studies (p < 0.00001). Dementia patients had significantly increased overall readmission rate (OR 1.18; 95% CI, 1.08-1.29, p < 0.001). They had higher complication rates for urinary tract infections (RR 2.88; 95% CI, 2.45-3.40, p < 0.0001), pressure ulcers (RR 184; 95% CI, 1.31-1.46, p < 0.0001), pneumonia (RR 1.66; 95% CI, 1.36-2.02, p < 0.0001), delirium (RR 3.10; 95% CI, 2.31-4.15, p < 0.0001), and, dehydration and electrolyte imbalance (RR 1.87; 95% CI, 1.55-2.25, p < 0.0001). Dementia patients had more acute cardiac events (HR 1.16; 95% CI, 1.06-1.28, p 0.002), while fewer revascularization procedures (HR 0.12; 95% CI, 0.08-0.20, p < 0.001). Patients with dementia had lesser use of ITU (reduction by 7.5%; 95% CI, 6.9-8.1), ventilation (reduction by 5.4%; 95% CI, 5.0-5.9), and dialysis (reduction by 0.5%; 95% CI, 0.4-0.8).DiscussionCompared to older adult population, patients with dementia had poorer outcome. Despite higher mortality rate and readmission rate, they underwent fewer interventions and procedures.     

Prognostic value of B-type natriuretic peptide and its amino-terminal proBNP fragment for cardiovascular events with stratification by renal function

BackgroundBrain natriuretic peptide (BNP) and amino-terminal proBNP (NT-proBNP) are useful biomarkers for diagnosis and prediction of prognosis. Both of these peptides are elevated in patients with chronic kidney disease (CKD), but there is no evidence as to which peptide is the more suitable biomarker in patients with severe renal dysfunction.Methods and resultsThis retrospective cohort study evaluated patients with cardiovascular diseases (64.9 ± 11.7 years, mean ± SD). The end points were all-cause death and a composite end point of all-cause death, nonfatal myocardial infarction, nonfatal stroke, hospitalization for severe heart failure, and initiation of hemodialysis. Baseline plasma BNP and NT-proBNP levels, expressed as log-transformed data, were closely correlated in patients with CKD stages 1–3 (n = 998) (r² = 0.870, p < 0.001), whereas for CKD stages 4–5 (n = 85) there was a significant but weaker correlation (r² = 0.209, p < 0.001). During follow-up periods (51.3 ± 0.4 months), 132 patients died and 202 patients reached the composite end point. The area under the receiver operating characteristic curve (AUROC) for BNP and NT-proBNP were similar for CKD stages 1–3. However, for CKD stages 4–5, the AUC for mortality for BNP was 0.713 and that for NT-proBNP was 0.760, while the AUC for the composite end point for BNP was 0.666 and that for NT-proBNP was 0.720.ConclusionsBoth BNP and NT-proBNP are useful biomarkers for mortality and cardiovascular events, but NT-proBNP may be superior to BNP for CKD stages 4–5.     

Determining clinical benefits of drug-eluting coronary stents according to the population risk profile: A meta-regression from 31 randomized trials

BackgroundThe use of drug-eluting stents (DES) in unfavourable patients has been associated with higher rates of clinical complications and stent thrombosis, and because of that concerns about the use of DES in high-risk settings have been raised.ObjectiveThis study sought to demonstrate that the clinical benefit of DES increases as the risk profile of the patients increases.MethodsA meta-regression analysis from 31 randomized trials that compared DES and bare-metal stents, including overall 12,035 patients, was performed. The relationship between the clinical benefit of using DES (number of patients to treat [NNT] to prevent one episode of target lesion revascularization [TLR]), and the risk profile of the population (rate of TLR in patients allocated to bare-metal stents) in each trial was evaluated.ResultsThe clinical benefit of DES increased as the risk profile of each study population increased: NNT for TLR = 31.1–1.2 (TLR for bare-metal stents); p < 0.001. The use of DES was safe regardless of the risk profile of each study population, since the effect of DES in mortality, myocardial infarction, and stent thrombosis, was not adversely affected by the risk profile of each study population (95% confidence interval for β value 0.09 to 0.11, ? 0.12 to 0.19, and ? 0.03 to?0.15 for mortality, myocardial infarction, and stent thrombosis, respectively).ConclusionsThe clinical benefit of DES increases as the risk profile of the patients increases, without affecting safety.     

Safety and efficacy of everolimus-eluting stents compared with first-generation drug-eluting stents in patients undergoing primary percutaneous coronary intervention

ObjectiveTo assess the safety and efficacy everolimus-eluting stents (EES) compared with first-generation drug-eluting stents (DES) in patients with acute myocardial infarction (MI) undergoing primary percutaneous coronary intervention (PCI).BackgroundEES have been associated with improved clinical outcomes compared to paclitaxel-eluting stents (PES) and with similar outcomes compared to sirolimus-eluting stents (SES).MethodsA total of 520 patients who presented with ST-elevation myocardial infarction (STEMI) from 2003 to 2013, who underwent primary PCI with DES, were retrospectively analyzed. Of these, 247 received SES, 136 PES, and 137 EES. Patients were followed up to 2 years for major adverse cardiac events (MACE). Univariate and multivariate models detected correlates to outcome.ResultsEES implantation, compared with PES and SES, resulted in comparable rates of MACE (8.8% vs. 16.2%, p = 0.06 and 8.8% vs. 12.6%, respectively, p = 0.26), stent thrombosis, MI, and target lesion revascularization. Patients who received EES had lower rates of all-cause mortality (3.7% vs. 12.6% vs. 9.4%, p = 0.03) at 1-year follow up. However, in the univariate and multivariate analyses, stent type was not independently associated with the primary outcome or with all-cause mortality. Diabetes mellitus and number of stents implanted were independently associated with the primary outcome.ConclusionWhile EES seem to be associated with better outcome when compared to PES, the main correlates of STEMI patients are the presence of diabetes and number of stents implanted, and not the type of stent used for intervention.     

Interacción cardiorrenal y evolución de la insuficiencia cardiaca. ¿Tiene un papel la proteína de unión del factor de crecimiento de tipo insulina 2?

Introduction and objectivesPreliminary results suggest that high circulating insulin-like growth factor binding protein 2 (IGFBP2) levels are associated with mortality risk in heart failure (HF) patients. As IGFBP2 levels are increased in patients with chronic kidney disease (CKD), which is associated with a higher mortality risk in HF patients, we examined whether IGFBP2 is associated with CKD in HF patients, and whether CKD modifies the prognostic value of this protein in HF patients.MethodsHF patients (n = 686, mean age 66.6 years, 32.7% women) were enrolled and followed up for a median of 3.5 (min-max range: 0.1-6) years. Patients were classified as having CKD with decreased estimated glomerular filtration rate (eGFR < 60 mL/min/1.73 m²) or as having CKD with nondecreased eGFR (≥ 60 mL/min/1.73 m²). Serum IGFBP2 was detected by ELISA.ResultsIGFBP2 was increased (P < .001) in CKD patients with decreased eGFR (n = 290, 42.3%) compared with patients with nondecreased eGFR. IGFBP2 was directly associated with NT-proBNP (P < .001) and inversely associated with eGFR (P < .001), with both associations being independent of confounding factors. IGFBP2 was directly and independently associated with cardiovascular and all-cause death (P < .001) in the whole group of patients, but showed a stronger association with cardiovascular death in CKD patients with decreased eGFR (P for interaction < .05), improving risk prediction in these patients over clinically relevant risk factors.ConclusionsSerum IGFBP2 is associated with impaired renal function and prognosticates cardiovascular death in patients with HF and CKD with decreased eGFR. Thus, there is an effect modification of CKD on circulating IGFBP2 and on its association with cardiovascular mortality in HF patients.     

Prediction of cardiovascular events in pre-dialysis chronic kidney disease patients with normal SPECT myocardial perfusion imaging

PurposePatients with normal stress myocardial perfusion imaging (MPI) results generally have an excellent prognosis with <1% cardiovascular events/year. Chronic kidney disease (CKD) is an established risk factor for cardiovascular events. However, the estimated glomerular filtration rate (eGFR) varies considerably among patients with CKD. We evaluated the prognostic value of eGFR for patients with CKD who did not undergo hemodialysis and had no evidence of coronary artery disease (CAD).Methods and subjectsPatients with CKD (n = 108; 58 males; mean age: 74 years) with no CAD [no previous CAD and normal stress MPI results; summed stress score (SSS) <4] and with no history of hemodialysis were followed-up (mean duration: 24 months). CKD was defined by eGFR of <60 ml/min/1.73 m² and/or persistent proteinuria. Cardiovascular events included cardiac death, non-fatal myocardial infarction, and unstable angina.ResultsCardiovascular events were observed in 8 patients with CKD (7%). The following were determined as significant predictors of these events: age (hazard ratio = 1.14; p = 0.019), hemoglobin levels (hazard ratio = 0.69; p = 0.021), eGFR (hazard ratio = 0.94; p = 0.008), SSS (hazard ratio = 2.31; p = 0.012), and summed difference score (hazard ratio = 2.33; p = 0.014).ConclusionsPatients with CKD and with no previous CAD and normal stress MPI results (SSS < 4) may not exhibit an excellent cardiovascular prognosis. Further, a lower eGFR and stress MPI results may be the predictors of cardiovascular events. Thus, patients with a lower eGFR and/or normal stress MPI results (SSS < 4) may require continuous follow-up.     

Comparison between drug-eluting and bare metal stent on ST-elevation myocardial infarction outcome: Should second-generation drug-eluting stent be preferred?

Background and purposeAlthough several studies reported that drug-eluting stents (DES) are able to reduce restenosis incidence without increasing mortality, concerns still exist about their safety in ST-segment elevation myocardial infarction (STEMI) patients mainly for a possible higher rate of in-stent thrombosis. Recent evidence suggests a better safety profile of second-generation DES, but data on their outcome in STEMI are still poor. In this study we evaluated the impact on mortality and target lesion revascularization (TLR) of DES or bare metal stent (BMS) implantation in STEMI patients submitted to primary angioplasty.Methods and subjectsWe analyzed mortality and TLR in 1150 STEMI patients during a mean 43-month follow-up after DES (44.6%) or BMS (55.4%) implantation. A propensity score method was used to minimize bias. During follow-up, 223 deaths occurred.Essential resultsUnadjusted for potential confounders, DES implantation was associated with a significant reduction in all-cause mortality [hazard ratio (HR) 0.40; 95%CI 0.30–0.54] and TLR (HR 0.55; 95%CI 0.36–0.86); this latter was confirmed after propensity score analysis (HR 0.39; 95%CI 0.21–0.67). Second- (n = 179) vs. first- (n = 337) generation DES showed a further reduction in TLR (HR 0.17; 95%CI 0.05–0.57). Adjusted analyses showed a significant reduction in the combined end-point of all-cause mortality or TLR after both first- and second-generation DES vs. BMS implantation with a trend to a lower risk for second- vs. first-generation DES.Principal conclusionsDES implantation in STEMI patients showed a significant reduction in TLR and in the combined endpoint of TLR or mortality. Second-generation DES showed a more protective effect on the combined endpoint, suggesting that they would be preferred in this setting.     

Left main PCI: An observational analysis from large single-centre experience

BackgroundAlthough trials have shown efficacy of unprotected left main percutaneous coronary intervention (uLMPCI), data from Indian subcontinent are lacking. Hence, we planned this observational analysis of single-center uLMPCI data.ObjectivesTo study long-term outcome after uLMPCI and identify predictors of adverse outcome.MethodsCase details of 62 consecutive patients of uLMPCI between 2006 and 2013 were retrieved from a computerized database wherein detailed records were maintained.ResultsMean follow-up duration was 669.8 ± 404.2 days. Procedural success rate was 98.4%. Primary endpoint was composite of major adverse cardiovascular and cerebrovascular events (MACCE), which included cardiac death (CD), cerebrovascular accident (CVA), myocardial infarction (MI), and need for repeat intervention (RI) at three years. MACCE occurred in 13 (20.9%) patients. Cardiac death (CD), (including possible stent thrombosis), RI, and CVA occurred in 6 (9.7%), 5 (8%), and 2 (3.2%) patients, respectively. Overall three-year MACCE-free survival rate was 76.7%. Event-free survival rate was similar among patients who underwent uLMPCI alone and patients who underwent uLMPCI along with additional one-vessel PCI [(88.9% vs 81.8%), p = 0.492], while survival rate was lower in patients who underwent uLMPCI along with PCI of additional two or more vessels (40%, p = 0.036). Patients with syntax score ≤32 had higher event-free survival rate than those with syntax score >32 [(87.1% vs 33.3%), p = 0.001]. Syntax score >32 was the only independent predictor of adverse outcome.ConclusionuLMPCI is safe and effective alternative to CABG for LM alone and LM plus single-vessel disease with syntax score ≤32.     

Mild heart failure is a mortality marker after a non-ST-segment acute myocardial infarction

BackgroundThe Killip classification categorizes heart failure (HF) in acute myocardial infarction, and has a prognostic value. Although non-ST-elevation myocardial infarction (NSTEMI) is increasing steadily, little information is available about the prognostic value of low Killip class in this scenario. Our aim was to assess the prognostic value of mild HF in NSTEMI.Methods835 patients with NSTEMI between 2005 and 2007 were prospectively recruited. Patients in Killip-1 (K1 = 684) or Killip-2 class (K2 = 113) were selected (38, with K > 2, excluded). Clinical, angiographic, treatment strategies, and 30-day all-cause mortality, together with other cardiovascular outcomes were recorded.ResultsK2 patients were mostly women (K1 27.9% vs K2 48.0%, p < 0.001) and older (K1 66.6 years vs K2 73.8 years, p < 0.001) with a higher frequency of diabetes mellitus (p < 0.001) and hypertension (p < 0.001). Smoking was less frequent in the K2-group (p = 0.003). A previous infarction/revascularization history was similar in both groups. The infarction size, assessed by Troponin I/Creatin kinase, did not differ between groups (p = 0.378 and p = 0.855). Multivessel coronary disease and revascularization procedures were less common in group K2 (p = 0.015 and p = 0.005 vs group K1, respectively). Patients in K2 had a worse prognosis in terms of maximum Killip class, death and major adverse cardiovascular events (p < 0.001). After multivariate analysis, mild HF at presentation was an independent risk factor for mortality (OR = 6.50; IC 95%: 2.48–16.95; p < 0.001).ConclusionMild HF at presentation in NSTEMI is linked to a poor prognosis, with increased short-term mortality. Thus, a more aggressive approach including early cardiac catheterization and revascularization should be considered.     

All-cause and cardiovascular mortality risk in U.S. adults with and without type 2 diabetes: Influence of physical activity,pharmacological treatment and glycemic control

AimsThis study determined the joint association between physical activity, pharmacotherapy, and HbA1c control on all-cause and cardiovascular disease (CVD) mortality risk in adults with and without type 2 diabetes (T2D).Methods12,060 adults from NHANES III and NHANES continuous (1999–2002) surveys were used. Cox proportional hazards analyses were included to estimate mortality risk according to physical activity, pharmacotherapy, and glycemic control (HbA1c < 7.0%) status, with physically active, treated and controlled (goal situation) as the referent.ResultsCompared to the referent, adults with T2D who were uncontrolled, or controlled but physically inactive had a higher all-cause mortality risk (p < 0.05). Compared to the referent, only adults with T2D who were physically inactive had a higher CVD mortality risk, regardless of treatment or control status (p < 0.05). Normoglycemic adults had a similar all-cause and CVD mortality risk as the referent (p > 0.05).ConclusionsPhysical activity and glycemic control are both associated with lower all-cause and CVD mortality risk in adults with T2D. Adults with T2D who are physically active, pharmacologically treated, and obtain glycemic control may attain similar mortality risk as normoglycemic adults.     

Should Proximal LAD be treated differently? Insights from a large DES stent registry

BackgroundThe current revascularization treatment recommendation is different according to lesion location and a higher recommendation is given to surgery for proximal LAD (pLAD) lesions over PCI. This is based on previous studies and expert opinion. We aimed to investigate whether indeed there is a difference in outcome with respect to LAD lesion location while using a drug eluting stent (DES).MethodsThe NOBORI-2 trial, enrolled 3067 consecutive patients in 125 centers who were treated with DES for single and multivessel disease. We compared 834 [27.2%] patients who underwent PCI of the pLAD as part of their revascularization, to 2203 [71.8%] patients in which stenting to other lesion(s) but not the pLAD was performed.ResultsThe pLAD group had lower incidence of hypertension, peripheral vascular disease, prior PCI and CABG, but had more lesions treated [1.55 ± 0.8 vs. 1.35 ± 0.6], more stents implanted [1.98 ± 1.2 vs. 1.66 ± 1.0] and longer overall stent length [31.8 ± 20.2 vs. 28.2 ± 17.8 mm].There was no difference in the occurrence of the primary endpoint [cardiac death, myocardial infarction and target lesion revascularization] at 1 or 2 years of follow up between the pLAD and non pLAD [6.0% vs. 4.6%, p = 0.14 and 7.7% vs. 6.6%; p = 0.22, respectively]. The relief from anginal symptoms was similar. Multivariate analysis showed that pLAD location was not a variable that predicted MACE or TLF. Stent thrombosis rate was similar.ConclusionWhen considering PCI with DES, there is no difference in outcome between patients with and without proximal LAD lesions.