Cycle-ergometry stress testing and use of chronotropic reserve adjustment of ST depression for identification of significant coronary artery disease in clinical practice

Diagnostic reliability of indexations of peak exercise ST segment depression (DeltaST) for heart rate reserve (HRi) or chronotropic reserve (CR) to identify significant coronary artery disease (CAD) by cycle-ergometer exercise testing has not been evaluated previously. Exercise testing by upright cycle-ergometer (25 W/3 min) were performed in consecutive patients in primary prevention with history of exercise-related chest discomfort and cardiovascular risk factors, or with overt peripheral artery disease, with or type-2 diabetes associated with two or more additional cardiovascular risk factors. Coronary angiography was performed after the test to assess significant CAD. Three different criteria for definition of inducible myocardial ischemia were tested versus significant CAD: peak DeltaST>or=100 microV, ST/HRi>1.69 microV/bpm or ST/CR>1.76 microV/%. Diagnostic accuracy vs. CAD of DeltaST>or=100 microV, of ST/HRi>1.69 microV/bpm, and of ST/CR>1.76 microV/% were 78%, 72%, and 89% respectively; sensitivity and specificity of the three criteria were 91% and 50%, 84% and 43%, 88% and 93%, respectively. Abnormal ST/CR predicted CAD independent of risk factors, pre-test probability, and more strongly than DeltaST. Combination of ST/HRi and ST/CR criteria did not improve CAD prediction. In conclusions, in clinical setting in patients in primary prevention but with moderate-to-high pre-test probability of CAD, exercise testing by cycle-ergometry and use of ST/CR>1.76 microV/% showed elevated sensitivity and specificity, and the best accuracy for diagnosis of significant CAD.     

Incisional hernia repair after kidney transplantation in a tertiary high-volume center: outcomes from a 10-year retrospective cohort study

International Urology and Nephrology - Incisional hernia (IH) after Kidney Transplantation (KT) is a challenging complication due to both technical reasons and patients’ complexity. Data...     

Immunotherapy for hepatocellular carcinoma: A promising therapeutic option for advanced disease

Hepatocellular carcinoma (HCC) is the third leading cause of cancer-related deaths worldwide, and its incidence continues to increase. Despite improvements in both medical and surgical therapies, HCC remains associated with poor outcomes due to its high rates of recurrence and mortality. Approximately 50% of patients require systemic therapies that traditionally consist of tyrosine kinase inhibitors. Recently, however, immune checkpoint inhibitors have revolutionized HCC management, providing new therapeutic options. Despite these major advances, the different factors involved in poor clinical responses and molecular pathways leading to resistance following use of these therapies remain unclear. Alternative strategies, such as adoptive T cell transfer, vaccination, and virotherapy, are currently under evaluation. Combinations of immunotherapies with other systemic or local treatments are also being investigated and may be the most promising opportunities for HCC treatment. The aim of this review is to provide updated information on currently available immunotherapies for HCC as well as future perspectives.     

Evolución de pacientes tratados con armazones coronarios bioabsorbibles liberadores de everolimus tras su disolución completa

Introduction and objectivesLong-term outcomes of unselected patients treated with bioresorbable vascular scaffold (BVS) implantation are lacking, especially for the period after complete dissolution of the BVS. This study sought to evaluate 5-year outcomes in patients treated with BVS in routine practice.MethodsConsecutive patients who underwent implantation of everolimus-eluting BVS during routine clinical practice at 2 high-volume centres in Germany were studied. The patients were followed-up for up to 5 years. The primary endpoints of interest were the composite of death, myocardial infarction and target lesion revascularization, as well as definite scaffold thrombosis.ResultsA total of 419 patients (mean age 66.6 ± 10.9 years; 31.5% had diabetes) were included, of whom 38.9% presented with an acute coronary syndrome. Of the 527 lesions treated, 49.0% were classified as complex and 13.1% were bifurcation lesions. At 5 years, the composite clinical endpoint occurred in 33.1% of patients and definite scaffold thrombosis occurred in 4.7%. Most definite scaffold thrombosis occurred within 2 years after BVS implantation.ConclusionsIn patients treated with BVS implantation in routine clinical practice the rates of adverse clinical events at 5 years were high, including a considerable incidence of scaffold thrombosis.     

Clinical outcomes of patients treated with Nobori biolimus-eluting stent: Meta-analysis of randomized trials

Backgrounds

The Nobori is a new-generation, biodegradable-polymer coated, biolimus-eluting stent (BES) that has recently been investigated in several randomized trials with inconsistent results. The aim of this study was to assess the efficacy and safety of Nobori BES versus other drug-eluting stents (DES) in patients treated with percutaneous coronary intervention (PCI).

Methods

We undertook a meta-analysis of randomized trials investigating Nobori BES versus other DES. Primary efficacy and safety outcomes were target lesion revascularization (TLR) and definite/probable stent thrombosis (ST), respectively. Secondary outcomes were the composite of cardiac death/myocardial infarction (MI)/target vessel revascularization (TVR), MI and death.

Results

A total of 9114 PCI-patients randomly received Nobori BES (n = 5080) or other DES (n = 4034). This latter group comprised patients receiving everolimus- (n = 2533), sirolimus- (n = 1376) or paclitaxel-eluting stents (n = 125). Median follow-up was 11 months [interquartile range 9–12]. The Nobori BES versus other DES showed comparable risk of TLR (odds ratio [95% confidence interval] = 0.91 [0.57–1.46], p = 0.71). There was significant heterogeneity across trials due to significant lower TLR risk with Nobori BES versus paclitaxel-eluting stent (0.32 [0.10–0.98], p = 0.046; p for interaction = 0.009). Nobori BES versus other DES showed comparable risk of definite/probable ST (1.40 [0.66–2.97], p = 0.39), cardiac death/MI/TVR (1.05 [0.88–1.25], p = 0.59), MI (1.13 [0.87–1.48], p = 0.37) and death (1.09 [0.81–1.48], p = 0.56).

Conclusions

Nobori BES has comparable efficacy with other limus-eluting stents at 1-year follow-up. There is no difference in terms of safety profile between these stent platforms.     

Safety and efficacy of the Yukon Choice Flex sirolimus-eluting coronary stent in an all-comers population cohort

Aims

The use of biodegradable-polymer drug-eluting stents has been shown to provide favorable results when compared with durable polymer drug-eluting stents and long-term follow up data have recently shown significant reductions in terms of very late stent thrombosis.Aim of the present study was to assess the safety and efficacy profile of a novel biodegradable polymer DES, the Yukon Choice Flex sirolimus-eluting stent.

Methods

We report here the one-year clinical outcomes associated with the use of the Yukon Choice Flex sirolimus-eluting stent in an all-comers patient population. The present stent represents a further refinement of the stent platform tested in the ISAR TEST 3 and 4 randomized clinical trials. A total of 778 consecutive patients undergoing implantation of this stent were enrolled in the present observational study and prospectively followed for one year.

Results

The use of the Yukon Choice Flex stent in a patient population with complex coronary lesion morphology was associated with optimal immediate angiographic results. At one year follow up the rates of death, myocardial infarction, definite stent thrombosis and ischemia-driven target lesion revascularization were respectively 2.4%, 1.9%, 0.3% and 11.3%.

Conclusions

The use of the sirolimus-eluting biodegradable polymer Yukon Choice Flex stent in an all-comers population of patients with complex coronary artery disease is associated with a favorable safety and efficacy profile up to one year follow up.