Previous studies on exercise tolerance screening in asymptomatic individuals before starting physical activity were not cost-effective due to low specificity. However, given progress in diagnosing and treating coronary artery disease (CAD), a reevaluation of this approach is justified. We aimed to examine whether stress echocardiography (SE) would be cost-effective.

The study was conducted on asymptomatic individuals with no known coronary disease. The decision tree had two arms: in one arm, the subjects underwent stress echocardiography (SE) as a screening test before starting physical activity, and in the other, they did not. The probabilities and utilities of variables in the decision tree were taken from medical literature, and the costs of treatments were obtained from the Israeli Ministry of Health Tarif (HealthCare in Israel is universal, participation in one of four official health insurance organizations is compulsory, and "supplementary insurance" is optional). A 5-year Markov model and Monte Carlo simulation with 1000 iterations were used to assess cost-effectiveness from the insurer's perspective. The variables that had the most significant impact on cost-effectiveness were the prior risk of coronary disease and the frequency of physical activity in the population under study. When cost-effectiveness assessment of SE was conducted in subjects receiving optimal medical therapy (OMT) and revascularization either transcutaneously or with bypass surgery, both groups had almost identical benefits, with a slight advantage for those who did not undergo SE. However, the cost was higher for subjects who underwent SE, and the Incremental Cost-Effectiveness Ratio (ICER) favored the No-SE group. On the other hand, when subjects only received OMT without therapeutic catheterization or bypass surgery, a cost-effectiveness assessment of SE demonstrated a lower cost and higher benefit in the group that underwent SE. In fact, SE was found to be absolutely dominant, with a negative ICER of $(-)27,644, which means that performing SE not only adds effectiveness but also saves expenses. Finally, a cost-effectiveness evaluation was conducted to compare the benefits of performing exercise tolerance testing (ETT) without stress echocardiography in subjects receiving OMT without therapeutic catheterization or bypass surgery. The results showed that the group that underwent ETT had a slightly higher benefit at a higher cost, with an ICER of $1804. This value is much lower than a WTP (willingness-to-pay) of $50,000 per year.

Performing SE as a screening test before starting physical activity in asymptomatic individuals is not cost-effective when the therapeutic options include revascularization. However, when the therapeutic policy is medical therapy without revascularization - as recommended in current guidelines - performing SE screening tests improves subjects' utility and results in financial savings. Carrying out ETT also results in improved utility that is inferior to SE as a screening test. At the same time, the ICER for ETT is still much smaller than the WTP, so performing ETT is worthwhile in cases where SE is unavailable.

Severe left main coronary artery disease (LMD) poses a major treatment challenge in Latin America, where both percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG) are used.

This guideline was developed de novo using the GRADE approach. A multidisciplinary panel reviewed evidence from a systematic review of randomized trials comparing PCI and CABG, incorporating a comprehensive literature search of patient values and preferences and outcome utilities. Thresholds were assigned for each clinical outcome, from small to large effect.

Five randomized trials enrolling 4612 patients were included. At 30 days, PCI resulted in a large reduction in major bleeding and a small reduction in strokes. At 5 years, PCI was associated with a small to moderate increase of spontaneous myocardial infarction and a moderate to large increase in repeat revascularization. No important differences in short- or long-term mortality were observed between PCI and CABG. The overall certainty of evidence was rated low. There was a notable variability in patient values and a close call on the balance of effects.

For patients in Latin America with severe left main coronary artery disease, the guideline panel suggests either PCI or CABG. This is a conditional recommendation, based on low certainty in the evidence (⨁⨁◯◯). It applies when both procedures are clinically and anatomically appropriate and can be performed at centers meeting acceptable standards. The decision should be made through a shared decision-making process involving the patient and the multidisciplinary care team.

Percutaneous coronary intervention (PCI) is an established alternative to coronary artery bypass grafting for the treatment of select patients with unprotected left main (LM) coronary artery disease (CAD). This study evaluates the safety and clinical impact of treating additional coronary arteries during LM-PCI. Consecutive patients undergoing PCI with drug-eluting stents for unprotected LM-CAD between 2010 and 2021 at The Mount Sinai Hospital, New York, USA were eligible for inclusion. Patients were stratified based on whether they underwent treatment of the LM complex alone or had concomitant PCI to an additional vessel outside the LM complex. The primary outcome was major adverse cardiovascular events (MACE), a composite of death, myocardial infarction, or stroke, at 1 year following PCI. Among 869 consecutive patients (mean age 70.9, 33.0% female, 27.9 mean SYNTAX score) undergoing LM-PCI, 479 (55.1%) underwent treatment of the LM complex alone, and 390 (44.9%) had concomitant PCI of an additional non-LM vessel. Compared with LM complex PCI only, there were no significant differences in the rate of MACE at 1 year [HR 12.0% vs 13.3%; HR: 0.95; 95% CI (0.62-1.44), p = 0.797], even after adjustment for potential confounders [HR 12.0% vs 13.3%; HR: 0.87; 95% CI (0.56-1.36), p = 0.550]. In conclusion, in a large, real-world cohort of patients undergoing unprotected LM-PCI, treatment of an additional non-LM vessel did not increase the risk of MACE at 1 year compared to LM complex PCI alone.

To assess the three year outcomes of the no-touch vein harvesting technique in coronary artery bypass grafting surgery compared with the conventional approach.

Three year extended follow-up of the randomised PATENCY (graft patency between the no-touch vein harvesting technique and conventional approach in coronary artery bypass graft surgery) trial.

Seven cardiac surgery centres in China; enrolment between April 2017 and June 2019.

2655 participants aged 18 and older undergoing isolated coronary artery bypass grafting surgery.

Patients were randomly assigned 1:1 to the no-touch vein harvesting technique group or the conventional approach group during surgery and followed up.

Vein graft occlusion (based on computed tomography angiography) at three years.

Mean age of participants was 61 years (standard deviation ±8 years) and 22% were women. 99.4% (2621) attended the three year follow-up visit, while 86.5% (2281) received computed tomography angiography. At three years, the no-touch group showed a significantly lower vein graft occlusion rate (5.7% v 9.0%, P<0.001) than the conventional group (odds ratio 0.62, 95% confidence interval 0.48 to 0.80), with absolute risk difference of -3.2% (95% confidence interval -5.0% to -1.4%). The intention-to-treat analysis, including all 2655 randomised patients with multiple imputations for missing data, showed consistent findings, with occlusion rates of 6.1% in the no-touch group versus 9.3% in the conventional group (odds ratio 0.63, 95% confidence interval 0.51 to 0.81; absolute risk difference-3.1%, 95% confidence interval -4.9% to -1.4%; P<0.001). These results confirm the robustness of the no-touch technique in reducing vein graft occlusion.

The no-touch technique consistently and robustly reduced the risk of vein graft occlusion and several cardiac events by one third to one half within three years after coronary artery bypass grafting surgery.

ClinicalTrials.gov NCT03126409.

Cardiovascular diseases, a leading cause of death globally, impose significant health and economic burdens, particularly in countries like Iran. Coronary artery bypass grafting (CABG) is a common intervention for ischaemic heart disease, yet it entails a long recovery process with potential complications and psychological impacts. This study aims to evaluate the effectiveness of a prehabilitation programme (pre-CABG) on postoperative outcomes and discharge readiness in patients undergoing elective CABG.

This randomised controlled trial involves 60 patients diagnosed with coronary artery disease at Imam Khomeini Hospital Complex, Tehran. Participants will be randomly assigned to either the intervention group, receiving the pre-CABG programme, or the control group, receiving standard care. The pre-CABG programme includes patient education, stress management techniques, respiratory muscle training and nutritional guidance. Primary outcomes include discharge readiness, duration of intubation, Intensive Care Uniy (ICU) stay, occurrence of atelectasis, onset of mobility, hospital stay and levels of anxiety and depression. Secondary outcomes include the rate of 30-day readmissions. Data collection will involve standardised scales and checklists administered at various stages preoperation and postoperation.

The research study has received approval from the Research Ethics Committee at Tehran University of Medical Sciences' School of Nursing and Midwifery and Rehabilitation. All participants must provide written consent for their involvement in this study. The findings will be shared with appropriate groups and published in peer-reviewed journals.

The study is registered with the Iranian Registry of Clinical Trials under the ID IRCT20231019059768N1.

Long-term outcomes following percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG) might be changing because of improved techniques and better medical therapy. This final prespecified analysis of the Fractional Flow Reserve (FFR) versus Angiography for Multivessel Evaluation (FAME) 3 trial aimed to reassess their comparative effectiveness at 5 years.

FAME 3 was a multicentre, randomised trial comparing FFR-guided PCI using current-generation zotarolimus-eluting stents versus CABG in patients with three-vessel coronary artery disease not involving the left main coronary artery. 48 hospitals in Europe, USA and Canada, Australia, and Asia participated in the trial. Patients (aged ≥21 years with no cardiogenic shock, no recent ST segment elevation myocardial infarction, no severe left ventricular dysfunction, and no previous CABG) were randomly assigned to either PCI or CABG using a web-based system. At 1 year, FFR-guided PCI did not meet the prespecified threshold for non-inferiority for the outcome of death, stroke, myocardial infarction, or repeat revascularisation versus CABG. The primary endpoint for this intention-to-treat analysis was the 5-year incidence of the prespecified composite outcome of death, stroke, or myocardial infarction. The trial was registered at ClinicalTrials.gov, NCT02100722, and is completed; this is the final report.

Between Aug 25, 2014 and Nov 28, 2019, 757 of 1500 participants were assigned to PCI and 743 to CABG. 5-year follow-up was achieved in 724 (96%) patients assigned to PCI and 696 (94%) assigned to CABG. At 5 years, there was no significant difference in the composite of death, stroke, or myocardial infarction between the two groups, with 119 (16%) events in the PCI group and 101 (14%) in the CABG group (hazard ratio 1·16 [95% CI 0·89-1·52]; p=0·27). There were no differences in the rates of death (53 [7%] vs 51 [7%]; 0·99 [0·67-1·46]) or stroke (14 [2%] vs 21 [3%], 0·65 [0·33-1·28]), but myocardial infarction was higher in the PCI group than in the CABG group (60 [8%] vs 38 [5%], 1·57 [1·04-2·36]), as was repeat revascularisation (112 [16%] vs 55 [8%], 2·02 [1·46-2·79]).

At the 5-year follow-up, there was no significant difference in a composite outcome of death, stroke, or myocardial infarction after FFR-guided PCI versus CABG, although myocardial infarction and repeat revascularisation were higher with PCI. These results provide contemporary evidence to allow improved shared decision making between physicians and patients.

Medtronic and Abbott Vascular.

We aimed to assess the usefulness of lipoprotein(a) [Lp(a)] and LDL-C levels as potential predictors of coronary lesions' complexity in patients with premature coronary artery disease (pCAD).

This study enrolled 162 consecutive patients with pCAD undergoing coronary angiography. The SYNTAX score (SS) was used to assess coronary lesions' complexity. Linear discriminant analysis (LDA) was employed to construct a multivariate classification model enabling the prediction of coronary lesions' complexity in SS.

The Lp(a) levels among patients with SS ≥ 23 and with SS 1-22 were significantly higher than those with SS = 0 (p = 0.021 and p = 0.027, respectively). The cut-off point for the Lp(a) level of 63.5 mg/dl discriminated subjects with SS ≥ 23 from those with SS ≤ 22 (sensitivity 0.546, specificity 0.780; AUC 0.620; p = 0.027). An LDA-based model involving the Lp(a) level, age, sex and LDL-C provided improved discrimination performance (sensitivity 0.727, specificity 0.733, AUC 0.800; p = 0.0001).

Lp(a) levels in pCAD patients are associated with the advancement of coronary artery lesions in SS patients. An Lp(a) level of 63.5 mg/dl can be the cut-off point for the identification of subjects with SS ≥ 23. LDA-based modelling using Lp(a), LDL-C, age and gender may be an applicable tool for the preliminary identification of patients at risk of more complex coronary artery lesions.

Refractory angina (RA) is a debilitating condition characterized by persistent angina despite optimized medical therapy and limited options for further revascularization, leading to diminished quality of life and increased healthcare utilization. The RA patient population is rapidly expanding with significant unmet needs. Specialty clinics should be developed to focus on the long-term efficacy and safety of clinically available and novel treatment strategies, emphasizing quality of life.

Patient-focused Comprehensive Angina Relief (CARE) clinics can enhance care and outcomes by providing individualized management for complex RA. This review summarizes peer-reviewed articles from PubMed and trial data from ClinicalTrials.gov. We discuss the epidemiology and pathophysiology of RA, introduce standardized tools for evaluating angina and psychosocial factors, and address symptom management. We also review treatment options such as risk factor modification, medication, and complex revascularization. Additionally, we explore emerging therapies, including coronary sinus occlusion, regenerative therapy, and neuromodulation for 'no-option' RA.

In the next five years, patients with refractory chest pain with or without coronary artery disease will increasingly be referred to specialty clinics for follow-up. Conducting more randomized control clinical trials with larger population subsets will bring novel therapies to the forefront.

Heart failure and diabetes mellitus are major contributors to global morbidity and mortality, with their prevalence continuously rising, primarily due to aging populations and improvements in healthcare. These conditions often coexist or develop sequentially, leading to complex interactions that significantly influence the progression and management of both diseases. Furthermore, heart failure and diabetes are commonly associated with coronary artery disease, which presents a unique challenge in clinical management, particularly in the context of myocardial revascularization. The presence of diabetes exacerbates atherosclerotic progression and impairs endothelial function, while heart failure complicates the perfusion and recovery of myocardial tissue post-intervention. This narrative review delves into the underlying mechanisms contributing to revascularization failure in patients with heart failure and diabetes, emphasizing the importance of understanding these interactions for optimal treatment. The review also summarizes key findings from randomized controlled trials, examining evidence both in the general population and in specific subgroups, including the elderly and patients with left main coronary artery disease, chronic kidney disease, peripheral artery disease, and chronic obstructive pulmonary disease. Understanding these complexities is critical for improving patient outcomes.

Heart failure (HF) remains a leading cause of morbidity and mortality worldwide, with acute HF (AHF) or cardiogenic shock requiring rapid intervention to prevent fatal outcomes. Advances in temporary mechanical circulatory support (tMCS) devices have revolutionized the management of advanced HF, offering temporary, durable, and individualized support options. This manuscript reviews the pathophysiology and clinical presentation of AHF, the role of multi-disciplinary Heart Teams, and the growing importance of structured care networks in managing complex cases of HF. We explore the strategic deployment of tMCS in acute settings, device options, implications for patient outcomes, and current challenges in the field. This manuscript emphasizes the importance of team-based approaches and underscores the potential of tMCS devices in stabilizing patient haemodynamics, bridging to recovery or definitive therapy, and improving survival in patients facing high-risk HF.

The degree of left ventricular (LV) dysfunction is an independent risk factor for poor outcomes in patients with chronic coronary syndrome. Coronary artery bypass graft (CABG) is the standard care for the management of ischemic heart failure to improve symptoms and prognosis. However, the predictors of improvement are still uncertain.

To assess the effect of myocardial revascularization on LV function and symptoms in patients with CCS and reduced left ventricular ejection fraction (LVEF), as well as to identify the improvement predictors.

We retrospectively analyzed the data and clinical status of 136 consecutive patients with LVEF<50% that underwent CABG. During clinical follow-up echocardiographic LV function was reassessed at the short-term (3.6 months) and long-term (30.8 months), and compared to baseline.

Mean pre-operative LVEF was 40.9 ± 8.6% and wall motion score index (WMSI) was 1.99 ± 0.36, both improving at long-term to 48.1 ± 15.0% (p<0.001) and 1.75 ± 0.49 (p<0.001), respectively. We observed that 55.7% of the patients presented an improvement of LVEF≥10% and 58.1% in WMSI ≥10%. Univariate logistic regression analysis revealed that cerebrovascular disease was the only variable to be predictor of LVEF improvement. At the end of follow-up, we observed a reduction in the rate of patients in functional class III/IV when compared to baseline (65.4 vs. 10.3% - p<0.001).

Patients with CCS and reduced LVEF undergoing CABG experienced improvement in both LV contractile function and size, with beneficial response in functional class.

This study aimed to assess the predictive capacity of specialized pro-resolving mediators (SPMs) regarding the complexity and prognosis of coronary heart disease (CHD). Total of 602 CHD patients were included in this study and categorized into low-risk, medium-risk, and high-risk groups based on the Synergy Between Percutaneous Coronary Intervention with Taxus and Cardiac Surgery (SYNTAX) score. Follow-up was conducted for two years, during which patients were dichotomized into poor and good prognosis groups. Additionally, twenty healthy controls were incorporated. Plasma concentrations of lipoxin A4 (LXA4), resolvin D1 (RvD1), protectin D1 (PD1), C-reactive protein (CRP), interleukin-6 (IL-6), and IL-10 were quantified. Plasma LXA4, RvD1, PD1, and the ratios LXA4/IL-6, RvD1/IL-6, PD1/IL-6 exhibited a gradual decrease across control, low-risk, medium-risk, and high-risk groups and exhibited a negative correlation with the SYNTAX score. Spearman's correlation analysis revealed negative correlations between plasma LXA4, RvD1, PD1, and both CRP and IL-6, and positive correlations with IL-10. Multiple linear regression models demonstrated negative associations between plasma LXA4, RvD1, PD1, and SYNTAX score. Moreover, both univariate and multivariate binary logistic regression analyses identified plasma LXA4, RvD1, and PD1 as protective factors against medium/high-risk SYNTAX score categorization. In the poor prognosis group, plasma PD1 was reduced at short-term follow-up, and the ratios LXA4/IL-6, RvD1/IL-6, PD1/IL-6 were reduced at long-term follow-up. Plasma LXA4, RvD1, and PD1 demonstrated negative correlations with CHD complexity and potentially served as protective factors against CHD. Plasma PD1 provided predictive value for short-term prognosis, while the ratios LXA4/IL-6, RvD1/IL-6, PD1/IL-6 were indicative for long-term prognosis.

Achilles tendon ultrasonography is useful in diagnosing familial hypercholesterolemia, as it allows assessment of its thickening and structure. The association between structural abnormalities in the Achilles tendon and the severity of coronary artery disease (CAD) was investigated in a cross-sectional study. We conducted this study on 353 patients who underwent percutaneous coronary intervention (PCI). Ultrasound was used to examine the thickness and structural abnormalities of the Achilles tendon. Their CAD severity was assessed using the SYNTAX score before the first PCI. Abnormal findings on Achilles tendon ultrasonography were observed in 21 patients (5.9%). The SYNTAX score was compared between patients with and without abnormal Achilles tendon structure. The SYNTAX score was significantly higher in patients who had structural abnormalities but without thickening of the Achilles tendon (P = .002). Multivariate analysis revealed that abnormal Achilles tendon structure was one of the independent risk factors for an elevated SYNTAX score. In patients with CAD who underwent PCI, structural abnormalities in the Achilles tendon identified by ultrasonography were independently associated with an increase in the SYNTAX score.

Given the widespread use of percutaneous coronary intervention (PCI) for the treatment of unprotected left main coronary artery (ULMCA) disease, real-world data are needed to understand the current practice and identify pitfalls and potential benefits, especially for an older and frail population.

We conducted a retrospective analysis including all patients, namely 1000, who underwent PCI on ULMCA for de-novo lesions, at our high-volume Italian center without on-site cardiac surgery, from 2002 to April 2023. Cases of restenosis, stent thrombosis, and coronary artery bypass grafting (CABG) were excluded. The primary clinical endpoint is major adverse cardiovascular and cerebrovascular event (MACCE), a composite endpoint including all-cause mortality, unplanned revascularization, myocardial infarction and stroke. Secondary clinical endpoints included the individual components of MACCE. Angiographic follow-up data, derived from both elective and clinical-driven procedures, were extensively available. The primary angiographic endpoint is target lesion failure (TLF), defined as significant restenosis or stent thrombosis of the LMCA. We performed a dedicated analysis comparing patients with a protocol-driven elective angiographic follow-up to those without, to evaluate the potential impact of this strategy on clinical outcomes.

Our registry encompasses a real-world frail and compromised population, with most patients (75%) presenting with acute coronary syndrome. Angiographic follow-up data were available for 739 patients (73.9%), of whom 612 (82.8%) demonstrated good results of the previous PCI and 127 patients (17.2%) experienced TLF. Multivariate analysis identified insulin-dependent diabetes, moderate to severe renal impairment, and a two-stents bifurcation technique as independent predictors of TLF. Among bifurcation techniques, the highest restenosis rates were observed in the Culotte technique (33.3%), followed by T and protrusion (30%) and Minicrush (28.2%), while the single stent approach was associated with the lowest rate of TLF (12.8%, p = < 0.001). Clinical follow-up data were available for 966 patients, with a survival rate of 95% at 7 days, 86.1% at 1 year, and 70% at an average follow-up of 2033 days. Multivariate analysis identified age over 70 years, moderate to severe renal impairment, multivessel disease, ejection fraction lower than 40%, hemodynamic instability (HDI) and endotracheal intubation (ETI) as independent predictors of MACCE and all-cause mortality while intravascular imaging was found to be protective for both. A propensity score matched analysis comparing two homogenous cohorts of 131 patients with and without elective angiographic follow-up demonstrated a significant survival advantage in the elective follow-up group, highlighting the potential benefits of this strategy.

In the real world setting clinical outcomes of PCI for unprotected LMCA disease are good and mainly affected by age, renal impairment, lower ejection fraction, multivessel disease and by the severity of the clinical presentation (namely HDI and ETI), while intravascular imaging was found to be protective. Notably, insulin-dependent diabetes and two-stent technique are independent predictors of TLF but not of mortality, while renal impairment has a negative impact on both. An elective angiographic follow-up could provide a survival benefit in this setting.

The perioperative management of patients undergoing cardiac surgery is highly complex and involves numerous factors. There is a strong association between cardiac surgery and perioperative complications. The Brazilian Surgical Identification Study (BraSIS 2) aims to assess the incidence of death and early postoperative complications, identify potential risk factors, and examine both the demographic characteristics of patients and the epidemiology of cardiovascular procedures.

BraSIS 2 is a multicenter observational study of patients who undergo cardiac surgery and who are admitted to the intensive care unit. The primary objective is to describe the risk factors and incidence of mortality or severe postoperative complications occurring within the first 3 postoperative days of cardiac surgery or until intensive care unit discharge (whichever event occurs first). Severe postoperative complications include acute myocardial infarction, acute respiratory distress syndrome, cardiorespiratory arrest with return of spontaneous circulation, Kidney Disease Improving Global Outcomes stage ≥ 2, a new surgical approach being conducted in an unscheduled event of urgency or emergency, renal replacement therapy, septic shock, severe bleeding, severe hemodynamic instability, stroke, unplanned reintubation, and unplanned use of a circulatory assistance device. The secondary outcomes include the evaluation of patient characteristics and descriptions of the performed surgeries and administered anesthesia. This study will also assess intraoperative and postoperative complications, as well as risk factors associated with postoperative complications and mortality. We expect to recruit 500 patients from at least 10 Brazilian intensive care units. Trial registration: NCT06154473; partial results.

To compare outcomes of two different revascularization strategies in chronic kidney disease (CKD) patients: coronary artery bypass grafting (CABG) versus percutaneous coronary intervention (PCI).

We conducted this meta-analysis according to Preferred Reporting Items for Systematic Review and Meta-Analyses guidelines and registered with PROSPERO (CRD42021238659), evaluated studies comparing CABG and PCI in patients with CAD and CKD (defined by KDIGO guidelines). Data were extracted from PubMed, EMBASE and Cochrane from 2000 to 2023. The primary end-point was long-term major adverse cardiovascular and cerebrovascular event rates, with secondary end-points including 30-day mortality, stroke, myocardial infarction (MI) and repeat revascularization. Statistical analyses included Kaplan-Meier estimations, Cox regression, and meta-regression to address heterogeneity. Publication bias was assessed via funnel plots. No funding was received, and the authors report no conflicts of interest.

We included 33 studies with 402 300 patients (eGFR <60 ml/min/1.73 m2). The cohort comprised 132 314 coronary artery bypass graft and 269 986 PCI patients. Over 3 years, coronary artery bypass group provided protection against major adverse cardiac and cerebrovascular events, MI, and repeat revascularization compared to PCI. However, PCI showed better short-term outcomes, including lower 30-day mortality. Coronary artery bypass group was linked to a higher stroke risk over the 3-year follow-up.

Revascularization strategies for CKD and coronary artery disease patients should balance PCI's short-term benefits with CABG's long-term advantages.

Numerous techniques have been developed to minimize risk of perioperative stroke during coronary artery bypass grafting (CABG), including off-pump approach, preoperative and intraoperative imaging of the ascending aorta (CT scan and epiaortic ultrasound), anaortic CABG with bilateral internal thoracic artery, clampless devices for the construction of proximal anastomosis and minimal aortic manipulation with a single aortic inflow for all proximal grafts (piggyback proximal anastomosis). The aim of this study was to evaluate the clinical outcomes of CABG patients who underwent off pump CABG with proximal anastomosis constructed with the use of a clampless device and in a piggyback fashion.

This observational study included 112 consecutive patients undergoing CABG with the piggyback proximal technique at the Lankenau Heart Institute between June 2021 and January 2024. Primary endpoints included overall mortality, cardiac-related mortality, stroke, myocardial infarction, repeat revascularization. Intraoperative transit time flow measurement (TTFM) was also analyzed.

The mean age of the cohort was 67.8 ± 8.7 years, with 75.9% (85/112) being male. All patients underwent off-pump CABG. The piggyback anastomosis consisted of vein-on-vein (52.7%, 59/112), artery-on-vein (43.8%, 49/112), and double vein/artery configurations (3.6%, 4/112). Postoperatively, no strokes occurred. At 30 days no patient died or required repeat revascularization. The mean hospital stay was 5.5 [4.0-8.0] days. At a mean follow-up of 1.0 [0.5-1.7] years, no cardiac deaths were recorded, with an overall survival of 98.2% (110/112). Repeat piggyback revascularization was 3.6% (4/112) at a mean of 2.0 ± 0.5 years. TTFM demonstrated superior flow rates in artery-on-vein grafts [50 (40-70) ml/min] compared to vein-on-vein grafts [40 (30-53.5), p < 0.001].

When a proximal anastomosis cannot be avoided during off pump CABG, the combination of a piggyback proximal anastomosis together with the use of a clampless aortic device, demonstrated promising early mid-term outcomes almost nullifying the perioperative risk of clinical stroke. Intraoperative TTFM showed excellent flow rates, especially when arterial grafts were used. The technique is a viable option in high-risk patients with severe aortic disease, offering a safe and effective approach to multivessel revascularization with minimal aortic manipulation. Further studies with longer follow-up are warranted to confirm its long-term benefits.

Outcomes of deferring percutaneous coronary intervention (PCI) without invasive physiologic assessment for intermediate coronary lesions is uncertain. We sought to compare long-term outcomes between medical treatment and PCI of intermediate lesions without invasive physiologic assessment.

A total of 899 patients with intermediate coronary lesions between 50% and 70% diameter-stenosis were randomized to the conservative group (n=449) or the aggressive group (n=450). For intermediate lesions, PCI was performed in the aggressive group, but was deferred in the conservative group. The primary endpoint was major adverse cardiac events (MACE, a composite of all-cause death, myocardial infarction [MI], or ischemia-driven any revascularization) at 3 years.

The number of treated lesions per patient was 0.8±0.9 in the conservative group and 1.7±0.9 in the aggressive group (p=0.001). At 3 years, the conservative group had a significantly higher incidence of MACE than the aggressive group (13.8% vs. 9.3%; hazard ratio [HR], 1.49; 95% confidence interval [CI], 1.00-2.21; p=0.049), mainly driven by revascularization of target intermediate lesion (6.5% vs. 1.1%; HR, 5.69; 95% CI, 2.20-14.73; p<0.001). Between 1 and 3 years after the index procedure, compared to the aggressive group, the conservative group had significantly higher incidence of cardiac death or MI (3.2% vs. 0.7%; HR, 4.34; 95% CI, 1.24-15.22; p=0.022) and ischemia-driven any revascularization.

For intermediate lesions, medical therapy alone, guided only by angiography, was associated with a higher risk of MACE at 3 years compared with performing PCI, mainly due to increased revascularization.

ClinicalTrials.gov Identifier: NCT00743899.

The 2021 Percutaneous Coronary Intervention guidelines completed by American College of Cardiology/American Heart Association/Society for Cardiovascular Angiography and Interventions provide a set of guidelines regarding revascularization strategies. With emphasis on equity of care, multidisciplinary heart team use, revascularization for acute coronary syndrome, and stable ischemic heart disease, the guidelines create a thorough framework with recommendations regarding therapeutic strategies. In this comprehensive review, our aim is to summarize the 2021 revascularization guidelines and analyze key points regarding each recommendation.

The appropriate use criteria for revascularization of stable ischemic heart disease have not been evaluated using randomized data. Using data from the randomized ISCHEMIA trial (International Study of Comparative Health Effectiveness with Medical and Invasive Approaches; July 2012 to January 2018, 37 countries), the health status benefits of an invasive strategy over a conservative one were examined within appropriate use criteria scenarios.

Among 1833 participants mapped to 36 appropriate use criteria scenarios, symptom status was assessed using the Seattle Angina Questionnaire-7 at 1 year for each scenario and for each of the 6 patient characteristics used to define the scenarios. Coronary anatomy and SYNTAX(Synergy between percutaneous coronary intervention with Taxus and cardiac surgery) scores were measured using coronary computed tomography angiography. Treatment effects are expressed as an odds ratio for a better health status outcome with an invasive versus conservative treatment strategy using Bayesian hierarchical proportional odds models. Differences in the primary clinical outcome were similarly examined.

The mean age was 63 years, 81% were male, and 71% were White. Diabetes was present in 28% and multivessel disease in 51%. Most clinical scenarios favored invasive for better 1-year health status. The benefit of an invasive strategy on Seattle Angina Questionnaire angina frequency scores was reduced for asymptomatic patients (odds ratio [95% credible interval], 1.16 [0.66-1.71] versus 2.26 [1.75-2.80]), as well as for those on no antianginal medications. Diabetes, number of diseased vessels, proximal left anterior descending coronary artery location, and SYNTAX score did not effectively identify patients with better health status after invasive treatment, and minimal differences in clinical events were observed.

Applying the randomization scheme from the ISCHEMIA trial to appropriate clinical scenarios revealed baseline symptoms and antianginal therapy to be the primary drivers of health status benefits from invasive management. Consideration should be given to reducing the patient characteristics collected to generate appropriateness ratings to improve the feasibility of future data collection.

URL: https://www.clinicaltrials.gov; Unique identifier: NCT01471522.

The Coronary Artery Tree Description and Lesion Evaluation (CatLet©) angiographic scoring system is a newly developed tool to predict the long-term clinical outcomes for patients with acute myocardial infarction (AMI). This study aimed to evaluate the predictive value of this novel angiographic scoring system for cardiac mortality in AMI patients within 30 days of primary percutaneous coronary intervention (pPCI) in AMI patients.

Patients with AMI undergoing pPCI were consecutively enrolled between January 2012 and July 2013. The CatLet© score was calculated for all the lesions in the non-occlusive status and were tertile partitioned into three groups: CatLet-low ≤14 (N = 124), CatLet-mid 14-22 (N = 82), and CatLet-top ≥22 (N = 102). The primary endpoint was cardiac mortality at 30 days after the procedure. Survival curves were generated using the Kaplan-Meier method, and survival rates among the CatLet© score tertiles were compared using the Log-rank test. Furthermore, Cox regression analysis was performed to identify the associations between the predictors and clinical outcomes.

A total of 308 patients were included in the final analysis. The included patients were followed up for 30 days, with 19 (6.17%) cardiac death. Kaplan-Meier curves indicated that the CatLet-top tertile exhibited a significant increase in the risk of cardiac mortality when compared with the low and mid tertiles (p for trend <0.01); the CatLet© score remained an independent predictor of 30-day cardiac mortality in AMI patients after adjusting for clinical variables (HR (95% CI): 6.13 (1.29-29.17); p < 0.01). The multivariable analysis demonstrated that a per 1 unit increase in CatLet© score was associated with a 1.04 (1.01-1.06)-fold increased risk of cardiac death. The area under the receiver operating characteristic (ROC) curve (AUC) statistic for the CatLet© score was 0.80 (95% CI, 0.69-0.91), with a good calibration (χ2 = 12.92; p = 0.12).

The CatLet© score can be used to predict the short-term cardiac death in AMI patients. A CatLet© score ≥22 or ≥11 myocardial segments involved relative to the total 17 segments (the score divided by 2), including culprit or non-culprit vessels, accounting for 65% (11/17) of left ventricle mass involved, is significantly associated with poor prognosis. The current study has extended the application of the CatLet© score in clinical practice.

ChiCTR-POC-17013536. Registered 25 November, 2017, https://www.chictr.org.cn/showproj.html?proj=22814.

Non-ST-segment elevation acute coronary syndrome (NSTE-ACS) has a significant impact on cardiovascular mortality in elderly patients. Identification of high-risk patients is essential to optimize clinical management. This study investigates the relationship between the TyG index and CAD complexity, as measured by the SYNTAX score, in elderly patients with NSTE-ACS.

We performed a retrospective analysis of 216 patients aged >65 years undergoing coronary angiography stratified according to tertiles of the TyG index and the SYNTAX score (SYNTAX score ≤ 22 versus SYNTAX score > 22).

After adjustment for confounders, the TyG index was identified as an independent predictor of moderate/high scores (SYNTAX score > 22). As a continuous variable, it was significantly associated with moderate/high SYNTAX scores in both diabetic ( P  = 0.003) and nondiabetic groups ( P  = 0.004). When presented as a categorical variable, the TyG index remained a significant predictor after adjustment for sex, hypertension, BMI, and glomerular filtration rate. Compared with the T1 group, the risk of a moderate/high SYNTAX score was 5.410-fold (95% CI: 1.034-28.315; P  = 0.046) and 7.774-fold (95% CI: 1.836-32.916; P  = 0.005) higher in the T2 and T3 groups, respectively. The TyG index showed superior predictive ability for CAD complexity with an AUC of 0.747 compared with the AUC of 0.624 for HbA1c ( P  = 0.005).

This study showed that the TyG index is an independent predictor of moderate/high SYNTAX scores in elderly patients with NSTE-ACS, demonstrating superior predictive performance compared to HgA1c and highlighting its potential as a valuable tool for assessing CAD severity in this population.

Atherosclerosis is a systemic multifocal disease which most commonly involves branching points of the large and medium-sized arteries. The carotid intima-media thickness (c-IMT) is an established marker for increased cardiovascular risk and cerebrovascular disease. In this study, we aimed to establish the role of femoral intima-media thickness (FIMT) in predicting cardiovascular risk in angiographically confirmed patients of coronary artery disease (CAD) when compared with apparently healthy patients (having normal coronary angiogram).

A total of 114 consecutive patients presented at our institute with symptoms of CAD who underwent coronary angiogram were included in the study. After the coronary angiogram, patients were divided into three groups, group A having normal coronary angiogram, group B having CAD with a synergy between percutaneous coronary intervention with taxus and cardiac surgery (SYNTAX) score of more than 22, and group C having CAD with a SYNTAX score of 22 or less. The Doppler ultrasound of the bilateral femoral artery in each patient was done 1 day before a coronary angiogram and FIMT was recorded.

There was a significant difference (p-value -  < 0.001) found in the mean FIMT in patients with normal coronaries (mean FIMT - 0.49 ± 0.05) and patients having CAD (mean FIMT - 0.73 ± 0.17). The area under the receiver operating characteristic (ROC) curve of mean FIMT in predicting abnormal coronaries was 0.903 (95%CI 0.847-0.958, p < 0.001).

The FIMT has a strong correlation with coronary artery disease. With the help of this non-invasive tool, we can diagnose subclinical atherosclerosis and it may contribute to the prevention of CAD and its severe manifestations.

Coronary graft failure (CGF) may occur early after coronary bypass graft surgery (CABG). The study aimed to identify clinical and perioperative risk factors and to evaluate the long-term clinical impact of symptomatic early CGF.

Patients who underwent clinically indicated coronary angiography (CAG) prior to post-CABG discharge between 2012 and 2022 were included. Symptomatic early CGF was defined as a dysfunctional coronary graft, evaluated on clinically indicated CAG, caused by stenosis of the proximal or distal anastomosis or bypass conduit, bypass occlusion, thrombosis, reduced flow (TIMI < 1) and kinking/tenting. Patients were divided into symptomatic early CGF and non-early CGF groups. Kaplan-Meier and multivariate analysis estimated cumulative survival free of major adverse cardiovascular events (MACE: death, myocardial infarction and revascularisation) up to 5 years' follow-up and identified predictors of symptomatic early CGF.

A total of 92 patients (79% male, 66.1 ± 10 years old) were included, of whom 55 (59.8%) had symptomatic early CGF. Baseline characteristics, surgical parameters and post-surgical parameters potentially indicative of ischaemia were comparable between groups. Patients with symptomatic early CGF had a significantly lower MACE rate over a median follow-up period of 33 months (p = 0.023). Venous graft integration (p = 0.005), Y‑graft configuration (p = 0.002) and prolonged inotropic support (p = 0.032) were associated with symptomatic early CGF.

Symptomatic early CGF was observed in the majority of post-CABG patients undergoing clinically indicated CAG prior to discharge. Patients with symptomatic early CGF exhibited higher MACE rates over a median follow-up period of 33 months. Venous graft integration, Y‑graft configuration and prolonged use of inotropic agents were associated with symptomatic early CGF. However, these clinical findings should be interpreted with caution.

Different treatment approaches exist for non-ST elevation acute coronary syndrome (ACS) patients. This study assessed the systemic immune inflammatory response index (SIIRI) for its prognostic value and incremental clinical utility in determining optimal timing for percutaneous coronary intervention (PCI) in non-ST elevation myocardial infarction (NSTEMI) patients, particularly when troponin levels are initially negative.

This study included 1270 ACS patients: 437 STEMI, 422 NSTEMI, and 411 unstable angina. Patients were stratified by SIIRI levels measured at admission, and coronary artery disease severity was evaluated using the SYNTAX score. The primary endpoint was major adverse cardiovascular events (MACE), including cardiovascular death, non-fatal myocardial infarction, stroke, and revascularization. Secondary endpoints encompassed individual MACE components and heart failure hospitalisations.

The mean age was 54.93 years (83% male). SIIRI levels were significantly higher in STEMI patients (6.83 ± 6.43 × 10 5 ) compared to NSTEMI (4.5 ± 5.39 × 10 5 ) and unstable angina (3.48 ± 2.83 × 10 5 ) ( P  < 0.001). Area under the curve for SIIRI distinguished NSTEMI and unstable angina from STEMI (0.81 and 0.80), with optimal cut-off points of 4.80 × 10 5 and 4.25 × 10 5 . In NSTEMI, 24.6% presented within 2 h of symptom onset, were troponin-negative, yet had elevated SIIRI. Post-PCI, SIIRI > 4.93 × 10 5 correlated with increased MACE at 1 year (17.2% vs 5%).

NSTEMI and unstable angina patients with SIIRI values >4.80 × 10 5 and 4.25 × 10 5 respectively, may require urgent intervention (<2 h). SIIRI can be of significant utility in patients of NSTEMI who present earlier with negative troponins. SIIRI can also aid in identifying high-risk individuals post-PCI, providing a valuable tool for early and accurate assessment.

Coronary artery bypass (CABG) has evolved over the decades, supported by scientific evidence from robust studies. The downgrade of the recommendation for CABG in patients with multivessel coronary artery disease proposed by the 2021 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization and the 2023 ACC/AHA Chronic Coronary Disease Guidelines has brought this discussion to the fore, with prestigious cardiothoracic surgery societies such as AATS and STS not supporting these recommendations. The purpose of this article is to broaden this discussion in light of published studies.

Hybrid coronary revascularization is a clinical strategy that uses a combination of surgical revascularization and percutaneous coronary intervention (PCI). Data on the hybrid approach for coronary artery disease involving the left main (LM) are scarce. We analyzed our cohort of hybrid coronary revascularizations with minimally invasive direct coronary artery bypass (MIDCAB) using robotic left internal mammary artery harvesting and PCI for multivessel disease with and without LM involvement.

Between January 2013 and December 2020, 105 patients consecutively underwent robotic MIDCAB. Of those, 62 patients (59.1%) had multivessel coronary artery disease and underwent revascularization via the hybrid approach using robotic MIDCAB and PCI. Patients were then stratified into 2 groups for comparison: LM disease (n = 22, 35.5%) and non-LM disease (n = 40, 64.5%).

The SYNTAX scores were significantly lower in the non-LM group compared with the LM group (19.06 ± 6.41 vs 24.86 ± 7.04, P = 0.002). There were no other significant differences in demographics between the groups. There were no 30-day mortalities in either group. Freedom from major adverse cardiac and cerebrovascular events at 5 years was 72.2% in the non-LM group and 61.0% in the LM group (P = 0.89). There were no significant differences in 5-year overall survival (94.1% vs 83.3%, P = 0.074) or freedom from coronary reintervention (83.4% vs 75.4%, P = 0.699).

Hybrid robotic MIDCAB for patients with and without LM disease can be performed with acceptable results in selected patients. However, it is not possible to draw definitive conclusions regarding safety and efficacy compared with conventional coronary artery bypass grafting.

Coronary chronic total occlusions (CTOs) have been a point of interest of the medical community for the last decade. The natural history of CTOs was for a long time unknown, as the presence of a single CTO was the most frequent cause for the exclusion of patients from randomized controlled trials (RCTs). Recent CTO RCTs have failed to show any benefit in terms of hard endpoints as major adverse cardiovascular events, but have shown a significant improvement in quality of life, as well in the frequency of angina; however, these studies are characterized by the limitation of the short duration of their follow-up period. Real-world data from observational studies indicate a significant improvement in cardiovascular death and overall mortality, suggesting that the results depend on the duration of the follow-up, and not on the procedure per se. The aim of the current review is to summarize all the existing RCTs, and to analyze the most important registries, as well as to present the current development of techniques to boost the successful interventional treatment of CTOs.

Choosing optimal revascularization strategies for patients with obstructive coronary artery disease (CAD) remains a clinical challenge. While randomized controlled trials offer population-level insights, gaps remain regarding personalized decision-making for individual patients. We applied off-policy reinforcement learning (RL) to a composite data model from 41,328 unique patients with angiography-confirmed obstructive CAD. In an offline setting, we estimated optimal treatment policies and evaluated these policies using weighted importance sampling. Our findings indicate that RL-guided therapy decisions outperformed physician-based decision making, with RL policies achieving up to 32% improvement in expected rewards based on composite major cardiovascular events outcomes. Additionally, we introduced methods to ensure that RL CAD treatment policies remain compatible with locally achievable clinical practice models, presenting an interpretable RL policy with a limited number of states. Overall, this novel RL-based clinical decision support tool, RL4CAD, demonstrates potential to optimize care in patients with obstructive CAD referred for invasive coronary angiography.

The care of elderly patients with coronary artery disease (CAD) undergoing percutaneous coronary interventions (PCIs) presents unique challenges due to age-related physiological and functional changes. With the global population aging rapidly, this demographic change affects a growing proportion of individuals requiring PCI. However, advanced age is associated with increased susceptibility to ischemic and bleeding complications, driven by physiological changes such as altered coagulation, vascular stiffness, and declining organ function. These factors complicate the management of CAD, making the balance between reducing thrombotic events and minimizing bleeding risks particularly challenging. Antiplatelet therapy is central to post-PCI management, but its benefits and risks differ significantly in elderly patients compared to younger populations. Tools like the PRECISE-DAPT and ARC-HBR provide guidance on dual antiplatelet therapy duration and bleeding risk stratification. However, their applicability and predictive accuracy in elderly patients remain areas of active investigation. This underscores the need for improved risk assessment methods tailored to the unique needs of aging individuals. In this review, we explore the epidemiological, pathophysiological, and clinical aspects of CAD in elderly patients, emphasizing the impact of aging on disease presentation and outcomes. Furthermore, we assess current risk stratification tools and discuss their limitations in predicting adverse events in older populations. By synthesizing these insights, we aim to highlight the complexities of managing elderly CAD patients and identify opportunities for optimizing personalized care to achieve better outcomes in this vulnerable group.

The long-term outcomes of percutaneous coronary intervention (PCI) vs. coronary artery bypass grafting (CABG) in patients with non-ST-segment elevation myocardial infarction (NSTEMI) and multivessel disease remain debated.

The Swedish Web-system for Enhancement and Development of Evidence-based care in Heart disease Evaluated According to Recommended Therapies registry was used to analyse 57 097 revascularized patients with NSTEMI with multivessel disease in Sweden from January 2005 to June 2022. The primary endpoint was all-cause mortality, encompassing both in-hospital and long-term mortality; the secondary endpoints included myocardial infarction (MI), stroke, new revascularization, and heart failure. Multilevel logistic regression with follow-up time as a log-transformed offset variable and double-robust adjustment with the instrumental variable method were applied to control for known and unknown confounders.

Percutaneous coronary intervention was the primary therapy in 42 190 (73.9%) patients, while 14 907 (26.1%) received CABG. Percutaneous coronary intervention patients were generally older with more prior cardiovascular events, whereas CABG patients had higher incidences of diabetes, hypertension, left main and three-vessel disease, and reduced ejection fraction. Over a median follow-up of 7.1 years, PCI was associated with higher risks of death [adjusted odds ratio (aOR) 1.67; 95% confidence interval (CI) 1.54-1.81] and MI (aOR 1.51; 95% CI 1.41-1.62) but there was no significant difference in stroke. Repeat revascularization was three times more likely to PCI (aOR 3.01; 95% CI 2.57-3.51), while heart failure risk was 15% higher (aOR 1.15; 95% CI 1.07-1.25). Coronary artery bypass grafting provided longer survival within 15 years, especially in patients under 70 years of age, with left main disease or left ventricular dysfunction, though this benefit diminished over shorter time horizons.

Coronary artery bypass grafting is associated with lower risks of mortality, MI, repeat revascularization, and heart failure in patients with NSTEMI, particularly in high-risk subgroups. However, its survival benefit lessens with shorter life expectancy.