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Shuja MH, Shakil F, Ali SH, Uddin QS, Noman A, Iqbal J, Ahmed M, Sajid F, Ansari HW, Farhan SA, Ansari HUH, Farhan SH, Nasir MM, Qazi S, Majid M. Comparison of percutaneous coronary intervention vs coronary artery bypass graft for left main coronary artery disease in patients with prior cerebrovascular disease: A systematic review, meta-analysis and meta-regression. INTERNATIONAL JOURNAL OF CARDIOLOGY. CARDIOVASCULAR RISK AND PREVENTION 2025; 24:200370. [PMID: 39877074 PMCID: PMC11772956 DOI: 10.1016/j.ijcrp.2025.200370] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/22/2024] [Revised: 12/24/2024] [Accepted: 01/07/2025] [Indexed: 01/31/2025]
Abstract
Background Previous studies suggest similar cardiovascular (CV) benefits for either percutaneous coronary intervention (PCI) or coronary artery bypass graft (CABG) in patients with left main coronary artery disease (LMCAD). However, limited data exist on the influence of prior cerebrovascular disease (CEVD). Thus, we aim to compare the CV outcomes in patients with LMCAD and prior CEVD, undergoing either PCI or CABG. Methods A comprehensive search from (January 2000 to August 2024) identified three relevant studies. Outcomes analyzed included all-cause mortality, major adverse cardiac and cerebrovascular events (MACCE), myocardial infarction (MI), and risk of stroke in patients undergoing either PCI or CABG for LMCAD. Data analysis employed a random effects model and presented hazard ratios (HR) along with their 95 % confidence intervals (CI). Results Three studies involving 760 patients (361 PCI, 399 CABG) were included. PCI was associated with a significantly higher risk of MACCE (HR = 2.56; 95 % CI = 1.23-5.37; p = 0.01; I2 = 86 %) and MI (HR = 2.97; 95 % CI = 1.72-5.13; p < 0.0001; I2 = 0 %) compared to CABG. No significant differences were observed in all-cause mortality (HR = 1.35; 95 % CI = 0.92-1.98; p = 0.12; I2 = 0 %) or recurrent stroke (HR = 0.83; 95 % CI = 0.40-1.70; p = 0.60; I2 = 1 %). The risk of repeat revascularization was higher in PCI, though not statistically significant (HR = 3.44; 95 % CI = 0.50-23.60; p = 0.21; I2 = 70 %). Conclusion PCI significantly elevates the risk of MACCE and MI in patients with LMCAD and prior CEVD compared to CABG. However, risks of all-cause mortality, repeat stroke, and revascularization were non-significant. Comorbidities may drive the elevated risk, underscoring the need for tailored strategies in this population.
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Affiliation(s)
| | - Firzah Shakil
- Department of Internal Medicine, Dow University of Health Sciences, Pakistan
| | - Syed Hassaan Ali
- Department of Internal Medicine, Dow University of Health Sciences, Pakistan
| | - Qazi Shurjeel Uddin
- Department of Internal Medicine, Dow University of Health Sciences, Pakistan
| | - Ayesha Noman
- Department of Internal Medicine, Dow University of Health Sciences, Pakistan
| | - Javed Iqbal
- Nursing Department Communicable Diseases Centre Hamad Medical Corporation, Doha, Qatar
| | - Muhammad Ahmed
- Department of Internal Medicine, Dow University of Health Sciences, Pakistan
| | - Faiza Sajid
- Department of Medicine, Liaquat National Hospital and Medical College, Pakistan
| | - Haya Waseem Ansari
- Department of Medicine, Liaquat National Hospital and Medical College, Pakistan
| | - Syed Ahmed Farhan
- Department of Internal Medicine, Dow University of Health Sciences, Pakistan
| | | | - Syed Husain Farhan
- Department of Internal Medicine, Dow University of Health Sciences, Pakistan
| | - Muhammad Moiz Nasir
- Department of Internal Medicine, Dow University of Health Sciences, Pakistan
| | - Sana Qazi
- Department of Internal Medicine, Dow University of Health Sciences, Pakistan
| | - Muhammad Majid
- Department of Internal Medicine, AdventHealth Sebring, Sebring, FL, USA
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Meynet P, Improta R, Carbone ML, Pecoraro M, Pagliassotto I, Di Pietro G, Demetres M, Bruno F, Comitini G, Leone A, Martinengo E, Siliano S, D'Ascenzo F, Chieffo A, De Ferrari GM, Gaudino M, Mancone M, Di Franco A, De Filippo O. Percutaneous coronary intervention versus coronary artery bypass grafting in left main disease according to patients' sex: A meta-analysis. Eur J Clin Invest 2025; 55:e14348. [PMID: 39543458 PMCID: PMC11744918 DOI: 10.1111/eci.14348] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2024] [Accepted: 10/30/2024] [Indexed: 11/17/2024]
Abstract
BACKGROUND The role of sex in choosing between coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI) for unprotected left main coronary artery (ULMCA) disease has gained interest. METHODS Randomized controlled trials and adjusted observational studies comparing PCI versus CABG in ULMCA patients with outcomes by sex were included. The primary endpoint was major adverse cardiovascular events (MACE), with secondary endpoints being all-cause mortality and repeated revascularization. RESULTS Ten studies (3 randomized, 7 observational) involving 22,141 ULMCA disease patients (13,411 PCI, 8730 CABG) with a median 5-year follow-up were included. Among males, PCI was associated with a higher risk of MACE (HR 1.18, 95% CI 1.01-1.38), while no significant difference was seen in females. However, moderator analysis showed no significant interaction between sex and revascularization strategy for MACE (p for interaction .422). No differences in all-cause mortality were observed between PCI and CABG for either sex. Repeated revascularization risk was significantly higher with PCI for both sexes (HR 3.51, 95% CI 2.21-5.59 in males and HR 4.20, 95% CI 2.57-6.87 in females). CONCLUSIONS In males with ULMCA disease, CABG was associated with a lower risk of MACE compared to PCI, while no significant differences were seen in females. The lack of a significant interaction between sex and revascularization strategy suggests that these findings may not reflect true sex-based effect modification. PCI was linked to a higher risk of repeated revascularization in both sexes compared to CABG. TRIAL REGISTRATION The protocol was registered in the PROSPERO International Prospective Register of Systematic Reviews (ID: CRD42024537726).
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Affiliation(s)
- Pierre Meynet
- Division of Cardiology, Cardiovascular and Thoracic Department"Città della Salute e della Scienza" HospitalTurinItaly
- Department of Medical SciencesUniversity of TurinTurinItaly
| | - Riccardo Improta
- Department of Clinical Internal, Anaesthesiological and Cardiovascular SciencesSapienza University of RomeRomeItaly
| | - Maria Luisa Carbone
- Division of Cardiology, Cardiovascular and Thoracic Department"Città della Salute e della Scienza" HospitalTurinItaly
- Department of Medical SciencesUniversity of TurinTurinItaly
| | - Martina Pecoraro
- Division of Cardiology, Cardiovascular and Thoracic Department"Città della Salute e della Scienza" HospitalTurinItaly
- Department of Medical SciencesUniversity of TurinTurinItaly
| | - Ilaria Pagliassotto
- Division of Cardiology, Cardiovascular and Thoracic Department"Città della Salute e della Scienza" HospitalTurinItaly
- Department of Medical SciencesUniversity of TurinTurinItaly
| | - Gianluca Di Pietro
- Department of Clinical Internal, Anaesthesiological and Cardiovascular SciencesSapienza University of RomeRomeItaly
| | - Michelle Demetres
- Samuel J. Wood Library and C.V. Starr Biomedical Information CenterWeill Cornell MedicineNew YorkNew YorkUSA
| | - Francesco Bruno
- Division of Cardiology, Cardiovascular and Thoracic Department"Città della Salute e della Scienza" HospitalTurinItaly
| | - Gaia Comitini
- Department of Clinical Internal, Anaesthesiological and Cardiovascular SciencesSapienza University of RomeRomeItaly
| | - Attilio Leone
- Division of CardiologySG Moscati HospitalAvellinoItaly
- Department of Advanced Biomedical SciencesUniversity of Naples Federico IINaplesItaly
| | - Eleonora Martinengo
- Division of Cardiology, Cardiovascular and Thoracic Department"Città della Salute e della Scienza" HospitalTurinItaly
- Department of Medical SciencesUniversity of TurinTurinItaly
| | - Stefano Siliano
- Division of Cardiology, Cardiovascular and Thoracic Department"Città della Salute e della Scienza" HospitalTurinItaly
- Department of Medical SciencesUniversity of TurinTurinItaly
| | - Fabrizio D'Ascenzo
- Division of Cardiology, Cardiovascular and Thoracic Department"Città della Salute e della Scienza" HospitalTurinItaly
- Department of Medical SciencesUniversity of TurinTurinItaly
| | - Alaide Chieffo
- Interventional Cardiology UnitIRCCS San Raffaele Scientific InstituteMilanItaly
- Vita Salute San Raffaele UniversityMilanItaly
| | - Gaetano Maria De Ferrari
- Division of Cardiology, Cardiovascular and Thoracic Department"Città della Salute e della Scienza" HospitalTurinItaly
- Department of Medical SciencesUniversity of TurinTurinItaly
| | - Mario Gaudino
- Department of Cardiothoracic SurgeryWeill Cornell MedicineNew YorkNew YorkUSA
| | - Massimo Mancone
- Department of Clinical Internal, Anaesthesiological and Cardiovascular SciencesSapienza University of RomeRomeItaly
| | - Antonino Di Franco
- Department of Cardiothoracic SurgeryWeill Cornell MedicineNew YorkNew YorkUSA
| | - Ovidio De Filippo
- Division of Cardiology, Cardiovascular and Thoracic Department"Città della Salute e della Scienza" HospitalTurinItaly
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Gurgoglione FL, Niccoli G. What is New from the 2024 European Society of Cardiology Congress on the Management of Chronic Coronary Syndromes? Updated Guidelines and Trials. Eur Cardiol 2024; 19:e23. [PMID: 39651114 PMCID: PMC11622220 DOI: 10.15420/ecr.2024.43] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2024] [Accepted: 09/26/2024] [Indexed: 12/11/2024] Open
Affiliation(s)
| | - Giampaolo Niccoli
- Division of Cardiology, University of Parma, Parma University Hospital Parma, Italy
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Zhao X, Hao Y, Zhao X, Zhang H, Wang X, Li F, Zhang W, Yang M, Chen H, Zhu Z, Tang Y, Miao L, Li W, Yang Q, Guo N, Chen B, He Y, Ye Y, Zeng Y. Comparison of intravascular ultrasound-guided with optical coherence tomography-guided percutaneous coronary intervention for left main distal bifurcation lesions: Rationale and design of the ISOLEDS trial. Contemp Clin Trials 2024; 146:107691. [PMID: 39277167 DOI: 10.1016/j.cct.2024.107691] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2024] [Revised: 08/23/2024] [Accepted: 09/09/2024] [Indexed: 09/17/2024]
Abstract
BACKGROUND Percutaneous coronary intervention (PCI) can provide benefits for anatomically suitable left main coronary artery (LMCA) lesions. When compared to traditional coronary angiography (CAG) -guided PCI, the use of intravascular ultrasound (IVUS) guidance has shown significant long-term prognostic improvements in LMCA PCI. Optical coherence tomography (OCT) offers a higher axial resolution than IVUS. However, there is currently a lack of relevant randomized controlled trials investigating the use of OCT specifically for left main distal bifurcation lesions. METHODS The ISOLEDS trial is an ongoing multicenter study that aims to compare IVUS-guided PCI with OCT-guided PCI for patients with true LMCA distal bifurcation lesions. This prospective, randomized, controlled, non-inferiority trial will enroll a total of 664 patients with visually-defined Medina 1,1,1 or 0,1,1 classification of left main distal bifurcation lesions. The patients will be randomly assigned in a 1:1 ratio to either IVUS-guided or OCT-guided PCI. The primary endpoint is to assess the occurrence of target lesion failure (TLF) within 12 months after the procedure. After undergoing PCI, patients are required to visit the hospital for a 12-month clinical follow-up. During this clinical assessment, CAG can be performed to evaluate the status of target lesions. DISCUSSION The ISOLEDS trial represents the first attempt to compare two distinct intracoronary imaging techniques for guiding PCI in patients with true LMCA distal bifurcation lesions. By evaluating and comparing the outcomes of these two imaging techniques, the trial results will aid operators in selection of the most effective approach for guiding PCI in these patients.
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Affiliation(s)
- Xiliang Zhao
- Center for Coronary Artery Disease, Division of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Yongchen Hao
- Department of Epidemiology, Beijing Anzhen Hospital, Capital Medical University, Beijing Institute of Heart, Lung and Blood Vessel Diseases, Beijing, China
| | - Xiufeng Zhao
- Department of Cardiology, Handan First Hospital, Handan, China
| | - Haijun Zhang
- Department of Cardiology, Handan First Hospital, Handan, China
| | - Xianzhong Wang
- Department of Cardiology, Handan First Hospital, Handan, China
| | - Fangjiang Li
- Department of Cardiology, The First Affiliated Hospital of Hebei North University, Zhangjiakou, China
| | - Wenduo Zhang
- Department of Cardiology, Beijing Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Ming Yang
- Department of Cardiology, Peking Union Medical College Hospital, Peking Union Medical College & Chinese Academy of Medical Sciences, Beijing 100730, China
| | - Hui Chen
- Department of Cardiology, Cardiovascular Center, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Zhongyu Zhu
- Department of Cardiology, Central China Fuwai Hospital of Zhengzhou University, Henan Provincial People's Hospital Heart Center, Zhengzhou, China
| | - Yida Tang
- Department of Cardiology and Institute of Vascular Medicine, Peking University Third Hospital, and Key Laboratory of Molecular Cardiovascular Science, Ministry of Education, Beijing, China
| | - Lifu Miao
- Heart Center, The First Hospital of Tsinghua University, Beijing, China
| | - Weiming Li
- Heart Center and Beijing Key Laboratory of Hypertension, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
| | - Qing Yang
- Department of Cardiology, General Hospital, Tianjin Medical University, Tianjin, China
| | - Ning Guo
- Department of Cardiovascular Medicine, First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Bo Chen
- Department of Cardiology, Qinghai Province Cardiovascular and Cerebrovascular Disease Specialist Hospital, Xining, China
| | - Yong He
- Department of Cardiology, West China Hospital of Sichuan University, Chengdu, China
| | - Yicong Ye
- Center for Coronary Artery Disease, Division of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China.
| | - Yong Zeng
- Center for Coronary Artery Disease, Division of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China.
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Yan Y, Xu H, Zhao Y, Lin S, Zheng Y. Ticagrelor versus Clopidogrel in Patients with left main Coronary Artery Stenting. Cardiovasc Drugs Ther 2024:10.1007/s10557-024-07636-3. [PMID: 39460906 DOI: 10.1007/s10557-024-07636-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/21/2024] [Indexed: 10/28/2024]
Abstract
PURPOSE The left main (LM) coronary artery disease poses high risks for its special anatomical characteristics. Optimal antiplatelet therapy is still controversial in this disease. We aimed to investigate the efficacy and safety of ticagrelor and clopidogrel in patients with stent implantation in the LM coronary artery. METHODS We analyzed 3221 patients with stent implantation in the LM coronary artery from January 2011 to June 2022. Patients were separated into two groups: the ticagrelor group (n = 1550) and the clopidogrel group (n = 1671). Baseline data were balanced by propensity score matching. The primary endpoint was all-cause mortality, and secondary endpoints included cardiovascular death, myocardial infarction, stroke, stent thrombosis, or target vessel revascularization. The primary safety endpoint was major bleeding, defined as BARC 3, 5 bleeding. RESULTS After propensity score matching (n = 1228 in each group), ticagrelor was linked to a lower incidence of all-cause mortality compared with clopidogrel after a three-year follow-up (5.7% vs. 8.5%; HR:0.728; 95%CI:0.537-0.985, P = 0.040). Ticagrelor treatment reduced target lesion revascularization (3.3% vs. 6.4%; HR: 0.542; 95%CI: 0.371-0.791, P = 0.001) and stent thrombosis (1.6% vs. 3.7%; HR: 0.459; 95%CI: 0.271-0.776, P = 0.004). There was no significant difference in major bleeding between the two groups. Multivariate COX analysis suggested that age, heart rate, diabetes, prior myocardial infarction, hemoglobin, serum creatinine, ticagrelor, DAPT duration, LM true-bifurcation, LM stent diameters, and IVUS were independent predictive parameters of all-cause death. CONCLUSIONS Ticagrelor was associated with lower all-cause mortality and no increased risk of major bleeding compared to clopidogrel in LM stenting patients. Thus, ticagrelor can be considered a viable substitute for clopidogrel in LM disease.
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Affiliation(s)
- Yufeng Yan
- Department of Cardiology, Nanjing First Hospital, Nanjing Medical University, Nanjing, 210006, Jiangsu, China
| | - Haimei Xu
- Department of Cardiology, Nanjing First Hospital, Nanjing Medical University, Nanjing, 210006, Jiangsu, China
| | - Yingying Zhao
- Department of Cardiology, Nanjing First Hospital, Nanjing Medical University, Nanjing, 210006, Jiangsu, China
| | - Song Lin
- Department of Cardiology, Nanjing First Hospital, Nanjing Medical University, Nanjing, 210006, Jiangsu, China.
- Department of Cardiology, Nanjing First Hospital, Nanjing Medical University, No. 68 Changle Road, Qinhuai District, Nanjing, 210006, Jiangsu, China.
| | - Yaguo Zheng
- Department of Cardiology, Nanjing First Hospital, Nanjing Medical University, Nanjing, 210006, Jiangsu, China.
- Department of Cardiology, Nanjing First Hospital, Nanjing Medical University, No. 68 Changle Road, Qinhuai District, Nanjing, 210006, Jiangsu, China.
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Warisawa T, Sonoda S, Yamaji K, Amano T, Kohsaka S, Natsuaki M, Tsujita K, Hibi K, Kobayashi Y, Kozuma K. State-of-the-art percutaneous coronary intervention for left main coronary artery disease in Japan. Cardiovasc Interv Ther 2024; 39:386-402. [PMID: 39078544 DOI: 10.1007/s12928-024-01030-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2024] [Accepted: 07/08/2024] [Indexed: 07/31/2024]
Abstract
Percutaneous coronary intervention for left main coronary artery disease (LM-PCI) represents a high-risk yet life-saving procedure that has evolved significantly over the years. This review outlines the current state-of-the-art practices for LM-PCI in Japan in detail, emphasizing the integration of coronary physiology and intracoronary imaging alongside with evidence-based standardized technique using latest drug-eluting stents. These advancements enable precise lesion assessment, stent sizing, and optimal deployment, thereby enhancing procedural safety and efficacy. Despite discrepancies between current guidelines favoring coronary artery bypass grafting and real-world practice trends towards increased LM-PCI adoption, particularly in elderly populations with multiple comorbidities, careful patient selection and procedural planning are critical. Future perspectives include further refining LM-PCI through conducting randomized controlled trials integrating advanced techniques and addressing the issue of ostial left circumflex lesions and nationwide standardization of medical care for LM disease.
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Affiliation(s)
| | - Shinjo Sonoda
- Department of Cardiovascular Medicine, Saga University, 5-1-1, Nabeshima, Saga, 849-8501, Japan.
| | - Kyohei Yamaji
- Department of Cardiovascular Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Tetsuya Amano
- Department of Cardiology, Aichi Medical University, Aichi, Japan
| | - Shun Kohsaka
- Department of Cardiology, Keio University School of Medicine, Tokyo, Japan
| | - Masahiro Natsuaki
- Department of Cardiovascular Medicine, Saga University, 5-1-1, Nabeshima, Saga, 849-8501, Japan
| | - Kenichi Tsujita
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| | - Kiyoshi Hibi
- Department of Cardiology, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - Yoshio Kobayashi
- Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine, Chiba, Japan
| | - Ken Kozuma
- Department of Cardiology, Teikyo University Hospital, Tokyo, Japan
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7
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Vrints C, Andreotti F, Koskinas KC, Rossello X, Adamo M, Ainslie J, Banning AP, Budaj A, Buechel RR, Chiariello GA, Chieffo A, Christodorescu RM, Deaton C, Doenst T, Jones HW, Kunadian V, Mehilli J, Milojevic M, Piek JJ, Pugliese F, Rubboli A, Semb AG, Senior R, Ten Berg JM, Van Belle E, Van Craenenbroeck EM, Vidal-Perez R, Winther S. 2024 ESC Guidelines for the management of chronic coronary syndromes. Eur Heart J 2024; 45:3415-3537. [PMID: 39210710 DOI: 10.1093/eurheartj/ehae177] [Citation(s) in RCA: 120] [Impact Index Per Article: 120.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/04/2024] Open
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8
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Georges D, Kreft D, Doblhammer G. Coronary artery bypass grafting vs. drug-eluting stent implantation: the probabilities of reintervention, transition to severe care-need, nursing home, and death in patients with coronary artery disease within the first three years: evaluations based on health claims data in Germany. J Thorac Dis 2024; 16:4863-4874. [PMID: 39268109 PMCID: PMC11388224 DOI: 10.21037/jtd-24-251] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2024] [Accepted: 05/31/2024] [Indexed: 09/15/2024]
Abstract
Background Coronary artery bypass grafting (CABG) and drug-eluting stent implantation (DES) are established as central methods of revascularization for patients with coronary artery disease. This study aims to analyse the health trajectories of patients after first CABG or first, second or third DES within the first three years, with a focus on follow-up interventions, severe care need, transition into a nursing home, and death. Methods Based on health claims data (n=11,581), we estimated age-and sex standardized probabilities of reintervention, and of transition to severe care need, nursing home and death following initial CABG (n=2,008) or DES (n=9,573) for patients aged 50 years and older using logistic regression models and direct standardization. Up to three follow-up DES interventions and one follow-up CABG were considered. Results There was a fairly high probability of reintervention, particularly after a DES and within the first year. Follow-up interventions were more likely to involve DES than CABG. The probability of death was notably higher for CABG patients. The probabilities of severe care need and moving to a nursing home were slightly lower and similar across the revascularization methods and over time. Conclusions DES and CABG are often associated with a need for follow-up interventions. Depending on the procedure, however, the risk of repeat surgery or adverse health outcomes varies. DES is associated with a relatively high probability of follow-up revascularization and a nearly constant probability of negative health outcomes in the short and medium term. In contrast, within three years after a CABG, follow-up reinterventions are rather rare. However, this procedure is particularly associated with an increased risk of mortality and short-term transition into a nursing home.
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Affiliation(s)
- Daniela Georges
- Department of Sociology and Demography, University of Rostock, Rostock, Germany
| | - Daniel Kreft
- Department of Sociology and Demography, University of Rostock, Rostock, Germany
| | - Gabriele Doblhammer
- Department of Sociology and Demography, University of Rostock, Rostock, Germany
- German Centre for Neurodegenerative Diseases, Bonn, Germany
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9
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Kawczynski MJ, Gabrio A, Maessen JG, van 't Hof AWJ, Brophy JM, Gollmann-Tepeköylü C, Sardari Nia P, Vriesendorp PA, Heuts S. Percutaneous coronary intervention with drug-eluting stents versus coronary bypass surgery for coronary artery disease: A Bayesian perspective. J Thorac Cardiovasc Surg 2024:S0022-5223(24)00701-3. [PMID: 39173709 DOI: 10.1016/j.jtcvs.2024.08.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2024] [Revised: 07/24/2024] [Accepted: 08/06/2024] [Indexed: 08/24/2024]
Abstract
OBJECTIVES Coronary revascularization is frequently performed for coronary artery disease (CAD). This study aims to assess the totality of randomized evidence comparing percutaneous coronary intervention with drug-eluting stents (DES-PCI) with coronary artery bypass grafting (CABG) for CAD. METHODS A systematic search was applied to 3 electronic databases, including randomized trials comparing DES-PCI with CABG for CAD with 5-year follow-up. A Bayesian hierarchical meta-analytic model was applied. The primary outcome was all-cause mortality at 5 years; secondary outcomes were stroke, myocardial infarction, and repeat revascularization. End points were reported in median relative risks (RRs) and absolute risk differences, with 95% credible intervals (CrIs). Kaplan-Meier curves were used to reconstruct individual patient data. RESULTS Six studies comprising 8269 patients (DES-PCI, n = 4134; CABG, n = 4135) were included. All-cause mortality at 5 years was increased with DES-PCI (median RR, 1.23; 95% CrI, 1.01-1.45), with a median absolute risk difference of +2.3% (95% CrI, 0.1%-4.5%). For stroke, myocardial infarction, and repeat revascularization, the median RRs were 0.79 (95% CrI, 0.54-1.25), 1.84 (95% CrI, 1.23-2.75), and 1.80 (95% CrI, 1.51-2.16) for DES-PCI, respectively. In a sample of 1000 patients undergoing DES-PCI instead of CABG for CAD, a median of 23 additional deaths, 46 myocardial infarctions, and 85 repeat revascularizations occurred at 5 years, whereas 10 strokes were prevented. CONCLUSIONS The current data suggest a clinically relevant benefit of CABG over DES-PCI at 5 years in terms of mortality, myocardial infarction, and repeat revascularization, despite an increased risk of stroke. These findings may guide the heart-team and the shared decision-making process.
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Affiliation(s)
- Michal J Kawczynski
- Department of Cardiothoracic Surgery, Maastricht University Medical Centre (MUMC+), Maastricht, The Netherlands; Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, The Netherlands
| | - Andrea Gabrio
- Department of Methodology and Statistics, University Maastricht, Maastricht, The Netherlands
| | - Jos G Maessen
- Department of Cardiothoracic Surgery, Maastricht University Medical Centre (MUMC+), Maastricht, The Netherlands; Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, The Netherlands
| | - Arnoud W J van 't Hof
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, The Netherlands; Department of Cardiology, Maastricht University Medical Centre (MUMC+), Maastricht, The Netherlands; Department of Cardiology, Zuyderland Medisch Centrum, Heerlen, The Netherlands
| | - James M Brophy
- McGill University Health Centre, Centre for Health Outcome Research (CORE), Montreal, Quebec, Canada
| | | | - Peyman Sardari Nia
- Department of Cardiothoracic Surgery, Maastricht University Medical Centre (MUMC+), Maastricht, The Netherlands; Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, The Netherlands
| | - Pieter A Vriesendorp
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, The Netherlands; Department of Cardiology, Maastricht University Medical Centre (MUMC+), Maastricht, The Netherlands
| | - Samuel Heuts
- Department of Cardiothoracic Surgery, Maastricht University Medical Centre (MUMC+), Maastricht, The Netherlands; Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, The Netherlands.
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10
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Taggart DP. PCI versus CABG in coronary artery disease. Vascul Pharmacol 2024; 155:107367. [PMID: 38508356 DOI: 10.1016/j.vph.2024.107367] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2024] [Accepted: 03/15/2024] [Indexed: 03/22/2024]
Abstract
The evidence basis for percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG) in coronary artery disease (CAD) has become more firmly established over the last decade in view of new evidence from several large, randomized trials and propensity-matched registries. In comparison to PCI, CABG offers substantial survival benefits and significant reductions in myocardial infarction and need for repeat revascularization in multivessel disease in patients with intermediate and high severity disease, whereas for left main disease these benefits are largely observed in patients with the highest-severity disease. In general, the benefits of CABG are further enhanced in patients with diabetes and/or impaired ventricular function. In stable or urgent clinical situations most decisions for intervention should be agreed by a multidisciplinary group ('Heart Team'), incorporating the severity of CAD and the patient's overall clinical suitability and personal wishes for any proposed procedure.
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Affiliation(s)
- David P Taggart
- Cardiovascular Surgery, Nuffield Dept of Surgical Sciences, University of Oxford, John Radcliffe Hospital, United Kingdom.
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11
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Ambrosini AP, Fishman ES, Damluji AA, Nanna MG. Chronic Coronary Disease in Older Adults. Med Clin North Am 2024; 108:581-594. [PMID: 38548465 PMCID: PMC11040602 DOI: 10.1016/j.mcna.2023.12.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/02/2024]
Abstract
The number of older adults age ≥75 with chronic coronary disease (CCD) continues to rise. CCD is a major contributor to morbidity, mortality, and disability in older adults. Older adults are underrepresented in randomized controlled trials of CCD, which limits generalizability to older adults living with multiple chronic conditions and geriatric syndromes. This review discusses the presentation of CCD in older adults, reviews the guideline-directed medical and invasive therapies, and recommends a patient-centric approach to making treatment decisions.
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Affiliation(s)
| | - Emily S Fishman
- Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Abdulla A Damluji
- Inova Center of Outcomes Research, Inova Heart and Vascular Institute, Falls Church, VA, USA; Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Michael G Nanna
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, CT 06520, USA.
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12
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Formica F, Hernandez-Vaquero D, Tuttolomondo D, Gallingani A, Singh G, Pattuzzi C, Niccoli G, Lorusso R, Nicolini F. Results beyond 5-years of surgery or percutaneous approach in severe coronary disease. Reconstructed time-to-event meta-analysis of randomized trials. REVISTA ESPANOLA DE CARDIOLOGIA (ENGLISH ED.) 2024; 77:383-392. [PMID: 37816454 DOI: 10.1016/j.rec.2023.09.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Accepted: 09/20/2023] [Indexed: 10/12/2023]
Abstract
INTRODUCTION AND OBJECTIVES There is controversy about the optimal revascularization strategy in severe coronary artery disease (CAD), including left main disease and/or multivessel disease. Several meta-analyses have analyzed the results at 5-year follow-up but there are no results after the fifth year. We conducted a systematic review and meta-analysis of randomized clinical trials, comparing results after the fifth year, between coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI) using drug-eluting stents in patients with severe CAD. METHODS We analyzed all clinical trials between January 2010 and January 2023. The primary endpoint was all-cause mortality. The databases of the original articles were reconstructed from Kaplan-Meier curves, simulating an individual-level meta-analysis. Comparisons were made at certain cutoff points (5 and 10 years). The 10-year restricted median survival time difference between CABG and PCI was calculated. The random effects model and the DerSimonian-Laird method were applied. RESULTS The meta-analysis included 5180 patients. During the 10-year follow-up, PCI showed a higher overall incidence of all-cause mortality (HR, 1.19; 95%CI, 1.04-1.32; P=.008)]. PCI showed an increased risk of all-cause mortality within 5 years (HR, 1.2; 95%CI, 1.06-1.53; P=.008), while no differences in the 5-10-year period were revealed (HR, 1.03; 95%CI, 0.84-1.26; P=.76). Life expectancy of CABG patients was slightly higher than that of PCI patients (2.4 months more). CONCLUSIONS In patients with severe CAD, including left main disease and/or multivessel disease, there was higher a incidence of all-cause mortality after PCI compared with CABG at 10 years of follow-up. Specifically, PCI has higher mortality during the first 5 years and comparable risk beyond 5 years.
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Affiliation(s)
- Francesco Formica
- Department of Medicine and Surgery, University of Parma, Parma, Italy.
| | | | | | - Alan Gallingani
- Cardiac Surgery Unit, University Hospital of Parma, Parma, Italy
| | - Gurmeet Singh
- Department of Critical Care Medicine and Division of Cardiac Surgery, Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Canada
| | - Claudia Pattuzzi
- Department of Medicine and Surgery, University of Parma, Parma, Italy; Cardiac Surgery Unit, University Hospital of Parma, Parma, Italy
| | - Giampaolo Niccoli
- Department of Medicine and Surgery, University of Parma, Parma, Italy; Cardiology Unit, University Hospital of Parma, Parma, Italy
| | - Roberto Lorusso
- Cardio-Thoracic Department, Maastricht University Medical Centre, Heart and Vascular Centre, Maastricht, The Netherlands; Cardiovascular Research Institute Maastricht (CARIM), Maastricht, The Netherlands
| | - Francesco Nicolini
- Department of Medicine and Surgery, University of Parma, Parma, Italy; Cardiac Surgery Unit, University Hospital of Parma, Parma, Italy
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13
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Kosmidou I, Shahim B, Dressler O, Redfors B, Morice MC, Puskas JD, Kandzari DE, Karmpaliotis D, Brown WM, Lembo NJ, Banning AP, Kappetein AP, Serruys PW, Sabik JF, Stone GW. Incidence, Predictors, and Impact of Hospital Readmission After Revascularization for Left Main Coronary Disease. J Am Coll Cardiol 2024; 83:1073-1081. [PMID: 38479955 DOI: 10.1016/j.jacc.2024.01.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Revised: 12/14/2023] [Accepted: 01/03/2024] [Indexed: 03/26/2024]
Abstract
BACKGROUND The frequency of and relationship between hospital readmissions and outcomes after revascularization for left main coronary artery disease (LMCAD) are unknown. OBJECTIVES The purpose of this study was to study the incidence, predictors, and clinical impact of readmissions following percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG) for LMCAD. METHODS In the EXCEL (XIENCE Versus Coronary Artery Bypass Surgery for Effectiveness of Left Main Revascularization) trial, 1,905 patients with LMCAD were randomized to PCI vs CABG. The cumulative incidence of readmissions was analyzed with multivariable Anderson-Gill and joint frailty models to account for recurrent events and the competing risk of death. The impact of readmission on subsequent mortality within 5-year follow-up was determined in a time-adjusted Cox proportional hazards model. RESULTS Within 5 years, 1,868 readmissions occurred in 851 of 1,882 (45.2%) hospital survivors (2.2 ± 1.9 per patient with readmission[s], range 1-16), approximately one-half for cardiovascular causes and one-half for noncardiovascular causes (927 [49.6%] and 941 [50.4%], respectively). One or more readmissions occurred in 463 of 942 (48.6%) PCI patients vs 388 of 940 (41.8%) CABG patients (P = 0.003). After multivariable adjustment, PCI remained an independent predictor of readmission (adjusted HR: 1.22; 95% CI: 1.10-1.35; P < 0.0001), along with female sex, comorbidities, and the extent of CAD. Readmission was independently associated with subsequent all-cause death, with interaction testing indicating a higher risk after PCI than CABG (adjusted HR: 5.72; 95% CI: 3.42-9.55 vs adjusted HR: 2.72; 95% CI: 1.64-4.88, respectively; Pint = 0.03). CONCLUSIONS In the EXCEL trial, readmissions during 5-year follow-up after revascularization for LMCAD were common and more frequent after PCI than CABG. Readmissions were associated with an increased risk of all-cause death, more so after PCI than with CABG.
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Affiliation(s)
- Ioanna Kosmidou
- Memorial Sloan Kettering Cancer Center, New York and Weill Cornell College of Medicine, New York, New York, USA; Clinical Trials Center, Cardiovascular Research Foundation, New York, New York, USA
| | - Bahira Shahim
- Clinical Trials Center, Cardiovascular Research Foundation, New York, New York, USA
| | - Ovidiu Dressler
- Clinical Trials Center, Cardiovascular Research Foundation, New York, New York, USA
| | - Björn Redfors
- Clinical Trials Center, Cardiovascular Research Foundation, New York, New York, USA; Department of Cardiology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | | | - John D Puskas
- Mount Sinai Heart at Mount Sinai Saint Luke's, New York, New York, USA
| | | | - Dimitri Karmpaliotis
- Gagnon Cardiovascular Institute, Morristown Medical Center, Morristown, New Jersey, USA
| | | | - Nicholas J Lembo
- Memorial Sloan Kettering Cancer Center, New York and Weill Cornell College of Medicine, New York, New York, USA; Clinical Trials Center, Cardiovascular Research Foundation, New York, New York, USA
| | | | | | - Patrick W Serruys
- Department of Cardiology, NUIG, National University of Ireland, Galway, Ireland; Imperial College of Science, Technology and Medicine, London, United Kingdom
| | - Joseph F Sabik
- Department of Surgery, UH Cleveland Medical Center, Cleveland, Ohio, USA
| | - Gregg W Stone
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA.
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14
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Khawaja M, Britt M, Khan MA, Munaf U, Arshad H, Siddiqui R, Virk HUH, Alam M, Krittanawong C. Left Main Coronary Artery Disease: A Contemporary Review of Diagnosis and Management. Rev Cardiovasc Med 2024; 25:66. [PMID: 39077332 PMCID: PMC11263144 DOI: 10.31083/j.rcm2502066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2023] [Revised: 12/10/2023] [Accepted: 12/29/2023] [Indexed: 07/31/2024] Open
Abstract
Significant left main coronary artery disease is a very high-risk subgroup of coronary artery disease that is a crucial indicator of heightened morbidity and mortality rates. Despite its clinical significance, uncertainties persist regarding the optimal management strategy for patients, particularly given its phenotypic variations. Existing evidence-based guidelines offer insights into revascularization options, yet questions remain regarding long-term prognoses and clinical outcomes when comparing percutaneous coronary intervention to coronary artery bypass grafting. This comprehensive review aims to provide an in-depth analysis of contemporary strategies for the diagnosis, assessment, and treatment of left main coronary artery disease. By synthesizing current literature and addressing the evolving landscape of revascularization modalities, this review seeks to contribute valuable insights for clinicians and researchers grappling with the complexities of managing left main coronary artery disease.
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Affiliation(s)
- Muzamil Khawaja
- Department of Cardiology, Emory University, Atlanta, GA 30322, USA
| | - Michael Britt
- Department of Internal Medicine, Emory University, Atlanta, GA 30322, USA
| | - Muhammad Asad Khan
- Department of Family Medicine, West Chicago Immediate Care, West Chicago, IL 60185-2847, USA
| | - Uzair Munaf
- Department of Internal Medicine, Dow Medical College, 75300 Karachi, Pakistan
| | - Hassaan Arshad
- Department of Internal Medicine, Capital Health Regional Medical Centre, Trenton, NJ 08638-4143, USA
| | - Rehma Siddiqui
- Department of Internal Medicine, The University of Mississippi Medical Center, Jackson, MS 39216, USA
| | - Hafeez Ul Hassan Virk
- Harrington Heart & Vascular Institute, Case Western Reserve University, University Hospitals Cleveland Medical Center, Cleveland, OH 44106-2333, USA
| | - Mahboob Alam
- Department of Cardiology, The Texas Heart Institute, Baylor College of Medicine, Houston, TX 77030, USA
| | - Chayakrit Krittanawong
- Cardiology Division, NYU Langone Health and NYU School of Medicine, New York, NY 10016, USA
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15
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Affiliation(s)
- Fernando Alfonso
- Department of Cardiology, IIS-IP, CIBER-CV, Hospital Universitario de La Princesa, Universidad Autónoma de Madrid, C/ Diego de León 62, Madrid 28006, Spain
| | - Alexander Marschall
- Department of Cardiology, IIS-IP, CIBER-CV, Hospital Universitario de La Princesa, Universidad Autónoma de Madrid, C/ Diego de León 62, Madrid 28006, Spain
| | - Fernando Rivero
- Department of Cardiology, IIS-IP, CIBER-CV, Hospital Universitario de La Princesa, Universidad Autónoma de Madrid, C/ Diego de León 62, Madrid 28006, Spain
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16
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Lee Chuy K, Velazquez EJ, Lansky AJ, Jamil Y, Ahmad Y. Current Landscape and Future Directions of Coronary Revascularization in Ischemic Systolic Heart Failure: A Review. JOURNAL OF THE SOCIETY FOR CARDIOVASCULAR ANGIOGRAPHY & INTERVENTIONS 2023; 2:101197. [PMID: 39131064 PMCID: PMC11307589 DOI: 10.1016/j.jscai.2023.101197] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Revised: 09/25/2023] [Accepted: 09/26/2023] [Indexed: 08/13/2024]
Abstract
Ischemic heart disease is the largest cause of death worldwide and the most common cause of heart failure (HF). The incidence and prevalence of HF are increasing owing to an aging population and improvements in the acute cardiac care of previously fatal conditions such as myocardial infarction. Strategies to improve outcomes in patients with ischemic systolic HF are urgently needed. There is systematic underutilization of testing for coronary artery disease in patients with HF, and revascularization is performed in an even smaller minority despite evidence for reduced mortality with coronary artery bypass grafting (CABG) over medical therapy in the Surgical Treatment for Ischemic Heart Failure Extension Study. Percutaneous coronary intervention (PCI) is a less-invasive approach to coronary revascularization; however, the recent Revascularization for Ischemic Ventricular Dysfunction (REVIVED)-British Cardiovascular Intervention Society (BCIS2) trial failed to demonstrate a benefit of PCI compared with that of medical therapy in patients with ischemic systolic HF. The comparative effectiveness of PCI and CABG for patients with ischemic systolic HF remains unknown, particularly in the era of contemporary medical therapy. In this review, we discuss the benefit of CABG in ischemic systolic HF, its underutilization, and the unmet clinical need. We also review the recent REVIVED-BCIS2 trial comparing PCI to medical therapy, as well as upcoming randomized controlled trials of PCI for ischemic systolic HF and persistent evidence gaps that will exist despite anticipated data from ongoing trials. There remains a need for an adequately powered randomized controlled trials to establish the comparative clinical effectiveness of PCI vs CABG in ischemic systolic HF in the era of contemporary revascularization approaches and medical therapy, as well as trials of coronary revascularization in patients with HF with preserved ejection fraction or less severe forms of left ventricular systolic dysfunction.
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Affiliation(s)
- Katherine Lee Chuy
- Division of Cardiology, Loma Linda University Medical Center, Loma Linda, California
| | - Eric J. Velazquez
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Alexandra J. Lansky
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Yasser Jamil
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Yousif Ahmad
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, Connecticut
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17
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Varma PK. Revascularization strategy for left main coronary artery disease. Indian J Thorac Cardiovasc Surg 2023; 39:443-445. [PMID: 37609621 PMCID: PMC10441887 DOI: 10.1007/s12055-023-01546-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2023] [Revised: 05/21/2023] [Accepted: 05/23/2023] [Indexed: 08/24/2023] Open
Affiliation(s)
- Praveen Kerala Varma
- Department of Cardiovascular and Thoracic Surgery, Amrita Institute of Medical Sciences and Research Centre, Amrita Vishwa Vidyapeetham (Amrita University), Kochi, India
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18
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Virani SS, Newby LK, Arnold SV, Bittner V, Brewer LC, Demeter SH, Dixon DL, Fearon WF, Hess B, Johnson HM, Kazi DS, Kolte D, Kumbhani DJ, LoFaso J, Mahtta D, Mark DB, Minissian M, Navar AM, Patel AR, Piano MR, Rodriguez F, Talbot AW, Taqueti VR, Thomas RJ, van Diepen S, Wiggins B, Williams MS. 2023 AHA/ACC/ACCP/ASPC/NLA/PCNA Guideline for the Management of Patients With Chronic Coronary Disease: A Report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines. J Am Coll Cardiol 2023; 82:833-955. [PMID: 37480922 DOI: 10.1016/j.jacc.2023.04.003] [Citation(s) in RCA: 163] [Impact Index Per Article: 81.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/24/2023]
Abstract
AIM The "2023 AHA/ACC/ACCP/ASPC/NLA/PCNA Guideline for the Management of Patients With Chronic Coronary Disease" provides an update to and consolidates new evidence since the "2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS Guideline for the Diagnosis and Management of Patients With Stable Ischemic Heart Disease" and the corresponding "2014 ACC/AHA/AATS/PCNA/SCAI/STS Focused Update of the Guideline for the Diagnosis and Management of Patients With Stable Ischemic Heart Disease." METHODS A comprehensive literature search was conducted from September 2021 to May 2022. Clinical studies, systematic reviews and meta-analyses, and other evidence conducted on human participants were identified that were published in English from MEDLINE (through PubMed), EMBASE, the Cochrane Library, Agency for Healthcare Research and Quality, and other selected databases relevant to this guideline. STRUCTURE This guideline provides an evidenced-based and patient-centered approach to management of patients with chronic coronary disease, considering social determinants of health and incorporating the principles of shared decision-making and team-based care. Relevant topics include general approaches to treatment decisions, guideline-directed management and therapy to reduce symptoms and future cardiovascular events, decision-making pertaining to revascularization in patients with chronic coronary disease, recommendations for management in special populations, patient follow-up and monitoring, evidence gaps, and areas in need of future research. Where applicable, and based on availability of cost-effectiveness data, cost-value recommendations are also provided for clinicians. Many recommendations from previously published guidelines have been updated with new evidence, and new recommendations have been created when supported by published data.
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19
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Virani SS, Newby LK, Arnold SV, Bittner V, Brewer LC, Demeter SH, Dixon DL, Fearon WF, Hess B, Johnson HM, Kazi DS, Kolte D, Kumbhani DJ, LoFaso J, Mahtta D, Mark DB, Minissian M, Navar AM, Patel AR, Piano MR, Rodriguez F, Talbot AW, Taqueti VR, Thomas RJ, van Diepen S, Wiggins B, Williams MS. 2023 AHA/ACC/ACCP/ASPC/NLA/PCNA Guideline for the Management of Patients With Chronic Coronary Disease: A Report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines. Circulation 2023; 148:e9-e119. [PMID: 37471501 DOI: 10.1161/cir.0000000000001168] [Citation(s) in RCA: 476] [Impact Index Per Article: 238.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/22/2023]
Abstract
AIM The "2023 AHA/ACC/ACCP/ASPC/NLA/PCNA Guideline for the Management of Patients With Chronic Coronary Disease" provides an update to and consolidates new evidence since the "2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS Guideline for the Diagnosis and Management of Patients With Stable Ischemic Heart Disease" and the corresponding "2014 ACC/AHA/AATS/PCNA/SCAI/STS Focused Update of the Guideline for the Diagnosis and Management of Patients With Stable Ischemic Heart Disease." METHODS A comprehensive literature search was conducted from September 2021 to May 2022. Clinical studies, systematic reviews and meta-analyses, and other evidence conducted on human participants were identified that were published in English from MEDLINE (through PubMed), EMBASE, the Cochrane Library, Agency for Healthcare Research and Quality, and other selected databases relevant to this guideline. STRUCTURE This guideline provides an evidenced-based and patient-centered approach to management of patients with chronic coronary disease, considering social determinants of health and incorporating the principles of shared decision-making and team-based care. Relevant topics include general approaches to treatment decisions, guideline-directed management and therapy to reduce symptoms and future cardiovascular events, decision-making pertaining to revascularization in patients with chronic coronary disease, recommendations for management in special populations, patient follow-up and monitoring, evidence gaps, and areas in need of future research. Where applicable, and based on availability of cost-effectiveness data, cost-value recommendations are also provided for clinicians. Many recommendations from previously published guidelines have been updated with new evidence, and new recommendations have been created when supported by published data.
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Affiliation(s)
| | | | | | | | | | | | - Dave L Dixon
- Former Joint Committee on Clinical Practice Guideline member; current member during the writing effort
| | - William F Fearon
- Society for Cardiovascular Angiography and Interventions representative
| | | | | | | | - Dhaval Kolte
- AHA/ACC Joint Committee on Clinical Data Standards
| | | | | | | | - Daniel B Mark
- Former Joint Committee on Clinical Practice Guideline member; current member during the writing effort
| | | | | | | | - Mariann R Piano
- Former Joint Committee on Clinical Practice Guideline member; current member during the writing effort
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20
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Cai L, Wang W, Dai L. Risk factors for hypoglycemia in patients with type 2 diabetes mellitus after intensive insulin therapy and blood glucose monitoring strategy. Afr Health Sci 2023; 23:499-508. [PMID: 38223574 PMCID: PMC10782344 DOI: 10.4314/ahs.v23i2.58] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2024] Open
Abstract
Background To explore the risk factors for hypoglycemia in patients with type 2 diabetes mellitus (T2DM) after intensive insulin therapy and the blood glucose monitoring strategy. Methods A total of 172 T2DM patients diagnosed from March 2019 to March 2021 were randomly divided into training (n=115) and test sets (n=57), and given intensive insulin therapy. After treatment, the training set was divided into hypoglycemia (n=35) and non-hypoglycemia groups (n=80). Univariate and multivariate logistic regression analyses were performed. Then 120 patients were divided into instantaneous scanning glucose test system monitoring (observation) and glucometer monitoring (control) groups. The diagnostic values of the two methods were validated using receiver operator characteristic curves. Results Course of disease, body mass index, fasting C-peptide and creatinine were independent risk factors for hypoglycemia, while instantaneous scanning glucose test system monitoring and glucometer monitoring were protective factors (P<0.05). The model had high predictive value. The observation group had shorter time of blood glucose reaching the standard, smaller insulin dose, and lower risk of hypoglycemia than those of the control group (P<0.05). Conclusion During intensive insulin therapy by multiple subcutaneous injections, the clinical effect of instantaneous scanning glucose test system on T2DM patients is better than that of glucometer.
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Affiliation(s)
- Ling Cai
- Department of Outpatient, Nanjing First Hospital, Nanjing Medical University, Nanjing 210006, Jiangsu Province, China
| | - Weiping Wang
- Department of Endocrinology, Nanjing First Hospital, Nanjing Medical University, Nanjing 210006, Jiangsu Province, China
| | - Lian Dai
- Department of Nursing, Nanjing First Hospital, Nanjing Medical University, Nanjing 210006, Jiangsu Province, China
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21
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Showkathali R, Yalamanchi RP. Contemporary Left Main Percutaneous Coronary Intervention: A State-of-the-art Review. Interv Cardiol 2023; 18:e20. [PMID: 37435600 PMCID: PMC10331562 DOI: 10.15420/icr.2023.02] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2023] [Accepted: 02/13/2023] [Indexed: 07/13/2023] Open
Abstract
The majority of the left ventricular myocardium is supplied by the left main coronary artery. Atherosclerotic obstruction of the left main coronary artery therefore leads to significant myocardial jeopardy. Coronary artery bypass surgery (CABG) has been the gold standard for left main coronary artery disease in the past. However, advancements in technology have established percutaneous coronary intervention (PCI) as a standard, safe and reasonable alternative to CABG, with comparable outcomes. Contemporary PCI of left main coronary artery disease comprises careful patient selection, accurate technique guided by either intravascular ultrasound or optical coherence tomography and - if necessary - physiological assessment using fractional flow reserve. This review focuses on current evidence from registries and randomised trials comparing PCI with CABG, procedural tips and tricks, adjuvant technologies and the triumph of PCI.
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22
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Formica F, Gallingani A, Tuttolomondo D, Hernandez-Vaquero D, Singh G, Pattuzzi C, Maestri F, Niccoli G, Ceccato E, Lorusso R, Nicolini F. Long-term outcomes comparison between surgical and percutaneous coronary revascularization in patients with multivessel coronary disease or left main disease. A systematic review and study level meta-analysis of randomized trials. Curr Probl Cardiol 2023; 48:101699. [PMID: 36921648 DOI: 10.1016/j.cpcardiol.2023.101699] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Accepted: 03/08/2023] [Indexed: 03/18/2023]
Abstract
Recent randomized trials comparing coronary artery bypass graft (CABG) with percutaneous coronary intervention (PCI) utilizing drug-eluting stents in patients with left main (LMD) disease and/or multivessel disease (MVD), reported conflicting results. We performed a study level meta-analysis comparing the two interventions for the treatment of LMD or MVD. Using electronic databases, we retrieved 6 trials, between January, 2010 and December, 2022. Five-years Kaplan-Meier curves of endpoints where reconstructed. Comparisons were made by Cox-linear regression frailty model and by landmark analysis. A random-effect method was applied. 8269 patients were included and randomly assigned to CABG (n=4135) or PCI (n=4134). During 5-years follow-up, PCI showed a higher incidence of all-cause mortality [hazard ratio (HR) 1.28; 95% confidence interval (CI), 1.11-1.47; p<0.0001)], spontaneous myocardial infarction (MI) (HR 1.84; 95% CI, 1.54-2.19; p<0.0001) and repeat coronary revascularization (HR 1.96; 95% CI, 1.72-2.24; p<0.0001). There was no long-term difference between the two interventions for cardiovascular death (p=0.14) and stroke (p=0.20), although the incidence of stroke was higher with CABG within 30-days from intervention (p<0.0001). PCI was associated with an increased risk for composite endpoints (p<0.0001) and major cerebral and cardiovascular events. (p<0.0001). In conclusion, at 5-year follow-up, in patients with LMD and/or MVD there was a significant higher incidence of all-cause mortality, spontaneous MI and repeat revascularization with PCI compared to CABG. The incidence of stroke was higher with CABG during the post-procedural period, but no difference was found during 5-years follow-up. Longer follow-up is mandatory to better define outcome difference between the two interventions.
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Affiliation(s)
- Francesco Formica
- University of Parma, Department of Medicine and Surgery, Parma, Italy.
| | - Alan Gallingani
- Cardiac Surgery Unit, University Hospital of Parma, Parma, Italy
| | | | | | - Gurmeet Singh
- Department of Critical Care Medicine and Division of Cardiac Surgery, Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Canada
| | - Claudia Pattuzzi
- University of Parma, Department of Medicine and Surgery, Parma, Italy; Cardiac Surgery Unit, University Hospital of Parma, Parma, Italy
| | | | - Giampaolo Niccoli
- University of Parma, Department of Medicine and Surgery, Parma, Italy; Cardiology Unit, University Hospital of Parma, Parma, Italy
| | | | - Roberto Lorusso
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht, The Netherlands
| | - Francesco Nicolini
- University of Parma, Department of Medicine and Surgery, Parma, Italy; Cardiac Surgery Unit, University Hospital of Parma, Parma, Italy
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Park S, Park SJ, Park DW. Percutaneous Coronary Intervention Versus Coronary Artery Bypass Grafting for Revascularization of Left Main Coronary Artery Disease. Korean Circ J 2023; 53:113-133. [PMID: 36914602 PMCID: PMC10011221 DOI: 10.4070/kcj.2022.0333] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2022] [Accepted: 01/24/2023] [Indexed: 03/03/2023] Open
Abstract
Owing to a large-jeopardized myocardium, left main coronary artery disease (LMCAD) represents the substantial high-risk anatomical subset of obstructive coronary artery disease. For several decades, coronary artery bypass grafting (CABG) has been the "gold standard" treatment for LMCAD. Along with advances in CABG, percutaneous coronary intervention (PCI) has also dramatically evolved over time in conjunction with advances in the stent or device technology, adjunct pharmacotherapy, accumulated experiences, and practice changes, establishing its position as a safe, reasonable treatment option for such a complex disease. Until recently, several randomized clinical trials, meta-analyses, and observational registries comparing PCI and CABG for LMCAD have shown comparable long-term survival with tradeoffs between early and late risk-benefit of each treatment. Despite this, there are still several unmet issues for revascularization strategy and management for LMCAD. This review article summarized updated knowledge on evolution and clinical evidence on the treatment of LMCAD, with a focus on the comparison of state-of-the-art PCI with CABG.
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Affiliation(s)
- Sangwoo Park
- Department of Cardiology, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Korea
| | - Seung-Jung Park
- Department of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Duk-Woo Park
- Department of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea.
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24
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Kim T, Kang DY, Kim S, Lee JH, Kim AR, Lee Y, Oh HJ, Jang M, Lee J, Kim JH, Lee PH, Ahn JM, Park SJ, Park DW, PRECOMBAT Extended Study Investigators. Impact of Complete or Incomplete Revascularization for Left Main Coronary Disease: The Extended PRECOMBAT Study. JACC. ASIA 2023; 3:65-74. [PMID: 36873760 PMCID: PMC9982224 DOI: 10.1016/j.jacasi.2022.10.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/12/2022] [Revised: 10/11/2022] [Accepted: 10/17/2022] [Indexed: 01/26/2023]
Abstract
Background Whether complete revascularization (CR) or incomplete revascularization (IR) may affect long-term outcomes after PCI) and coronary artery bypass grafting (CABG) for left main coronary artery (LMCA) disease is unclear. Objectives The authors sought to assess the impact of CR or IR on 10-year outcomes after PCI or CABG for LMCA disease. Methods In the PRECOMBAT (Premier of Randomized Comparison of Bypass Surgery versus Angioplasty Using Sirolimus-Eluting Stent in Patients with Left Main Coronary Artery Disease) 10-year extended study, the authors evaluated the effect of PCI and CABG on long-term outcomes according to completeness of revascularization. The primary outcome was the incidence of major adverse cardiac or cerebrovascular events (MACCE) (composite of mortality from any cause, myocardial infarction, stroke, or ischemia-driven target vessel revascularization). Results Among 600 randomized patients (PCI, n = 300 and CABG, n = 300), 416 patients (69.3%) had CR and 184 (30.7%) had IR; 68.3% of PCI patients and 70.3% of CABG patients underwent CR, respectively. The 10-year MACCE rates were not significantly different between PCI and CABG among patients with CR (27.8% vs 25.1%, respectively; adjusted HR: 1.19; 95% CI: 0.81-1.73) and among those with IR (31.6% vs 21.3%, respectively; adjusted HR: 1.64; 95% CI: 0.92-2.92) (P for interaction = 0.35). There was also no significant interaction between the status of CR and the relative effect of PCI and CABG on all-cause mortality, serious composite of death, myocardial infarction, or stroke, and repeat revascularization. Conclusions In this 10-year follow-up of PRECOMBAT, the authors found no significant difference between PCI and CABG in the rates of MACCE and all-cause mortality according to CR or IR status. (Ten-Year Outcomes of PRE-COMBAT Trial [PRECOMBAT], NCT03871127; PREmier of Randomized COMparison of Bypass Surgery Versus AngioplasTy Using Sirolimus-Eluting Stent in Patients With Left Main Coronary Artery Disease [PRECOMBAT], NCT00422968).
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Affiliation(s)
- Taesun Kim
- Department of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Do-Yoon Kang
- Department of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Sehee Kim
- Department of Clinical Epidemiology and Biostatistics, Asan Medical Center, Seoul, Korea
| | - Jeen Hwa Lee
- Department of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Ah-Ram Kim
- Department of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - YeonJeong Lee
- Department of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Hyeon Jeong Oh
- Department of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Mihee Jang
- Department of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Junghoon Lee
- Department of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Ju Hyeon Kim
- Department of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Pil Hyung Lee
- Department of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jung-Min Ahn
- Department of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Seung-Jung Park
- Department of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Duk-Woo Park
- Department of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - PRECOMBAT Extended Study Investigators
- Department of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
- Department of Clinical Epidemiology and Biostatistics, Asan Medical Center, Seoul, Korea
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25
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Affiliation(s)
- Filippo Crea
- Department of Cardiovascular Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.,Department of Cardiovascular and Pulmonary Sciences, Catholic University of the Sacred Heart, Rome, Italy
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26
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Jabbour RJ, Curzen N. National Institute for Health and Care Excellence guidelines on myocardial revascularisation. Heart 2023:heartjnl-2022-321397. [PMID: 36631143 DOI: 10.1136/heartjnl-2022-321397] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Accepted: 12/09/2022] [Indexed: 01/13/2023] Open
Abstract
Cardiologists in the UK predominantly use the National Institute for Health and Care Excellence (NICE) and European Society of Cardiology guidelines to help guide decision-making. This article will appraise the current recommendations from NICE regarding myocardial revascularisation and compare them with other major international guidelines. While there are many similarities, subtle differences exist. These differences arise in part due to the evidence base at time of publication, as well as from the different healthcare systems that they are designed for, and from the cost-effectiveness models that dominate the methodology used by NICE. The clinical implications of the differences between the international guidelines will be analysed.
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Affiliation(s)
- Richard J Jabbour
- Cardiology, University Hospital Southampton NHS Foundation Trust, Southampton, UK.,Faculty of Medicine, University of Southampton, Southampton, UK
| | - Nick Curzen
- Cardiology, University Hospital Southampton NHS Foundation Trust, Southampton, UK .,Faculty of Medicine, University of Southampton, Southampton, UK
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27
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Uskela S, Eranti A, Kärkkäinen JM, Rissanen TT. Drug-coated balloon-only strategy for percutaneous coronary intervention of de novo left main coronary artery disease: the importance of proper lesion preparation. Front Med 2022; 17:75-84. [PMID: 36562952 DOI: 10.1007/s11684-022-0950-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2022] [Accepted: 06/28/2022] [Indexed: 12/24/2022]
Abstract
This retrospective single-center registry study included all consecutive patients who underwent percutaneous coronary intervention (PCI) for a de novo left main coronary artery lesion using drug coated-balloon (DCB)-only strategy between August 2011 and December 2018. To best of our knowledge, no previous studies of DCB-only strategy of treating de novo left main coronary artery disease, exist. The primary endpoint was major adverse cardiovascular events (MACEs) including cardiac death, non-fatal myocardial infarction, and target lesion revascularization (TLR). The cohort was divided into two groups depending on weather the lesion preparation was done according to the international consensus group guidelines. Sixty-six patients (mean age 75±8.6, 72% male), 52% of whom had acute coronary syndrome, underwent left main PCI with the DCB-only strategy. No procedural mortality and no acute closures of the treated left main occurred. At 12 months, MACE and TLR occurred in 24% and 6% of the whole cohort, respectively. If the lesion preparation was done according to the guidelines, the MACE and TLR rates were 21.2% and 1.9%. Left main PCI with the DCB only-strategy is safe leading to acceptable MACE and low TLR rates at one year, if the lesion preparation is done according to the guidelines.
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Affiliation(s)
- Sanna Uskela
- North Karelia Central Hospital-Heart Center, Tikkamaentie 16, Joensuu, 80210, Finland.
| | - Antti Eranti
- North Karelia Central Hospital-Heart Center, Tikkamaentie 16, Joensuu, 80210, Finland
| | - Jussi M Kärkkäinen
- Kuopio University Hospital, Puijonlaaksontie 2, Kuopio, Pohjois-Savo, 70210, Finland
| | - Tuomas T Rissanen
- Kuopio University Hospital, Puijonlaaksontie 2, Kuopio, Pohjois-Savo, 70210, Finland
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28
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Bernardi M, Morello A, Galli M. Complex percutaneous coronary intervention: what is the role of new-generation scoring balloons? Minerva Cardiol Angiol 2022; 70:686-688. [PMID: 36256437 DOI: 10.23736/s2724-5683.22.06123-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Affiliation(s)
- Marco Bernardi
- Department of Clinical, Internal Medicine, Anesthesiology and Cardiovascular Sciences, Sapienza University, Rome, Italy
| | - Alberto Morello
- Interventional Cardiovascular Unit, Pineta Grande Hospital, Castel Volturno, Caserta, Italy
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29
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Crea F. Controversies in cardiac surgery: left main coronary disease, arterial myocardial revascularization, and prosthetic valves in dialysis. Eur Heart J 2022; 43:4603-4605. [PMID: 36403731 DOI: 10.1093/eurheartj/ehac664] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Affiliation(s)
- Filippo Crea
- Department of Cardiovascular Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.,Department of Cardiovascular and Pulmonary Sciences, Catholic University of the Sacred Heart, Rome, Italy
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30
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A Practical Approach to Left Main Coronary Artery Disease. J Am Coll Cardiol 2022; 80:2119-2134. [DOI: 10.1016/j.jacc.2022.09.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2022] [Accepted: 09/07/2022] [Indexed: 11/22/2022]
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31
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Abstract
Traditionally, the treatment of left main coronary artery disease is recommended coronary artery bypass grafting because of its superior long-term outcomes compared with medical treatment and plain old balloon angioplasty. However, improvement of percutaneous coronary intervention technique and introduction of drug-eluting stent led to change of treatment strategy of left main coronary artery disease through cumulative data for revascularization that based on clinical evidence.
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Affiliation(s)
- Jinho Lee
- Department of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-ro 43-gil, Songpa-gu, Seoul 05505, Korea
| | - Duk-Woo Park
- Department of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-ro 43-gil, Songpa-gu, Seoul 05505, Korea.
| | - Seung-Jung Park
- Department of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-ro 43-gil, Songpa-gu, Seoul 05505, Korea.
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32
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Dąbrowski EJ, Kożuch M, Dobrzycki S. Left Main Coronary Artery Disease-Current Management and Future Perspectives. J Clin Med 2022; 11:jcm11195745. [PMID: 36233613 PMCID: PMC9573137 DOI: 10.3390/jcm11195745] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2022] [Revised: 09/22/2022] [Accepted: 09/26/2022] [Indexed: 02/05/2023] Open
Abstract
Due to its anatomical features, patients with an obstruction of the left main coronary artery (LMCA) have an increased risk of death. For years, coronary artery bypass grafting (CABG) has been considered as a gold standard for revascularization. However, notable advancements in the field of percutaneous coronary intervention (PCI) led to its acknowledgement as an important treatment alternative, especially in patients with low and intermediate anatomical complexity. Although recent years brought several random clinical trials that investigated the safety and efficacy of the percutaneous approach in LMCA, there are still uncertainties regarding optimal revascularization strategies. In this paper, we provide a comprehensive review of state-of-the-art diagnostic and treatment methods of LMCA disease, focusing on percutaneous methods.
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33
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Stachon P, Kaier K, Hehn P, Peikert A, Wolf D, Oettinger V, Staudacher D, Duerschmied D, Zirlik A, Zehender M, Bode C, von Zur Mühlen C. Coronary artery bypass grafting versus stent implantation in patients with chronic coronary syndrome and left main disease: insights from a register throughout Germany. Clin Res Cardiol 2022; 111:742-749. [PMID: 34453576 PMCID: PMC8397600 DOI: 10.1007/s00392-021-01931-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Accepted: 08/17/2021] [Indexed: 11/25/2022]
Abstract
BACKGROUND Recent randomized controlled trials have sparked debate about the optimal treatment of patients suffering from left main coronary artery disease. The present study analyzes outcomes of left main stenting versus coronary bypass grafting (CABG) in a nationwide registry in patients with chronic coronary syndrome (CCS). METHODS All cases suffering from CCS and left main coronary artery disease treated either with CABG or stent, were identified within the database of the German bureau of statistics. Logistic or linear regression models were used with 20 baseline patient characteristics as potential confounders to compare both regimens. RESULTS In 2018, 1318 cases with left main stenosis were treated with CABG and 8,920 with stent. Patients assigned for stenting were older (72.58 ± 9.87 vs. 68.63 ± 9.40, p < 0.001) and at higher operative risk, as assessed by logistic EuroSCORE (8.77 ± 8.45 vs. 4.85 ± 4.65, p < 0.001). After risk adjustment, no marked differences in outcomes were found for in-hospital mortality and stroke (risk adjusted odds ratio (aOR) for stent instead of CABG: aOR mortality: 1.08 [95% CI 0.66; 1.78], p = 0.748; aOR stroke: 0.59 [0.27; 1.32], p = 0.199). Stent implantation was associated with a reduced risk of relevant bleeding (aOR 0.38 [0.24; 0.61], p < 0.001), reduced prolonged ventilation time (aOR 0.54 [0.37 0.79], p = 0.002), and postoperative delirium (aOR 0.16 [0.11; 0.22], p < 0.001). Furthermore, stent implantation was associated with shorter hospital stay (- 6.78 days [- 5.86; - 7.71], p < 0.001) and lower costs (- €10,035 [- €11,500; - €8570], p < 0.001). CONCLUSION Left main stenting is a safe and effective treatment option for CCS-patients suffering from left main coronary artery disease at reasonable economic cost. Coronary artery bypass grafting versus stent implantation in patients with chronic coronary syndrome and left main disease: insights from a register throughout Germany. All cases with chronic coronary syndrome and left main stenosis treated in 2018 in Germany either with left main stenting or coronary bypass grafting were extracted from a nation-wide database. In-hospital outcomes were compared after logistic regression analysis.
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Affiliation(s)
- Peter Stachon
- Department of Cardiology and Angiology I, University Heart Center Freiburg-Bad Krozingen, Faculty of Medicine, University of Freiburg, Freiburg, Germany.
- Center of Big Data Analysis in Cardiology (CeBAC), Department of Cardiology and Angiology I, University Heart Center Freiburg-Bad Krozingen, Faculty of Medicine, University of Freiburg, Freiburg, Germany.
| | - Klaus Kaier
- Center of Big Data Analysis in Cardiology (CeBAC), Department of Cardiology and Angiology I, University Heart Center Freiburg-Bad Krozingen, Faculty of Medicine, University of Freiburg, Freiburg, Germany
- Institute of Medical Biometry and Statistics, Faculty of Medicine and Medical Center, University of Freiburg, Freiburg, Germany
| | - Philip Hehn
- Center of Big Data Analysis in Cardiology (CeBAC), Department of Cardiology and Angiology I, University Heart Center Freiburg-Bad Krozingen, Faculty of Medicine, University of Freiburg, Freiburg, Germany
- Institute of Medical Biometry and Statistics, Faculty of Medicine and Medical Center, University of Freiburg, Freiburg, Germany
| | - Alexander Peikert
- Department of Cardiology and Angiology I, University Heart Center Freiburg-Bad Krozingen, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Dennis Wolf
- Department of Cardiology and Angiology I, University Heart Center Freiburg-Bad Krozingen, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Vera Oettinger
- Department of Cardiology and Angiology I, University Heart Center Freiburg-Bad Krozingen, Faculty of Medicine, University of Freiburg, Freiburg, Germany
- Center of Big Data Analysis in Cardiology (CeBAC), Department of Cardiology and Angiology I, University Heart Center Freiburg-Bad Krozingen, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Dawid Staudacher
- Department of Cardiology and Angiology I, University Heart Center Freiburg-Bad Krozingen, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Daniel Duerschmied
- Department of Cardiology and Angiology I, University Heart Center Freiburg-Bad Krozingen, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Andreas Zirlik
- Department of Cardiology, University Hospital Graz, Graz, Austria
| | - Manfred Zehender
- Department of Cardiology and Angiology I, University Heart Center Freiburg-Bad Krozingen, Faculty of Medicine, University of Freiburg, Freiburg, Germany
- Center of Big Data Analysis in Cardiology (CeBAC), Department of Cardiology and Angiology I, University Heart Center Freiburg-Bad Krozingen, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Christoph Bode
- Department of Cardiology and Angiology I, University Heart Center Freiburg-Bad Krozingen, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Constantin von Zur Mühlen
- Department of Cardiology and Angiology I, University Heart Center Freiburg-Bad Krozingen, Faculty of Medicine, University of Freiburg, Freiburg, Germany
- Center of Big Data Analysis in Cardiology (CeBAC), Department of Cardiology and Angiology I, University Heart Center Freiburg-Bad Krozingen, Faculty of Medicine, University of Freiburg, Freiburg, Germany
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34
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Percutaneous coronary intervention versus coronary artery bypass grafting in left main coronary artery disease: A review. Rev Port Cardiol 2022. [DOI: 10.1016/j.repc.2021.06.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
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35
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Bittl JA, Tamis-Holland JE, Lawton JS. Does Bypass Surgery or Percutaneous Coronary Intervention Improve Survival in Stable Ischemic Heart Disease? JACC Cardiovasc Interv 2022; 15:1243-1248. [PMID: 35583361 DOI: 10.1016/j.jcin.2022.05.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2022] [Accepted: 05/05/2022] [Indexed: 11/18/2022]
Affiliation(s)
- John A Bittl
- Scientific Publishing Committee, American College of Cardiology, Washington, DC, USA.
| | | | - Jennifer S Lawton
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
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36
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Meta-Analysis of Percutaneous Coronary Intervention Versus Coronary Artery Bypass Grafting for Left Main Narrowing. Am J Cardiol 2022; 173:39-47. [PMID: 35393084 DOI: 10.1016/j.amjcard.2022.02.044] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2021] [Revised: 02/11/2022] [Accepted: 02/18/2022] [Indexed: 12/12/2022]
Abstract
Randomized controlled trials (RCTs) comparing percutaneous coronary intervention (PCI) with drug-eluting stents and coronary artery bypass grafting (CABG) for patients with left main coronary artery disease (LMCAD) have reported conflicting results. We performed a systematic review up to May 23, 2021, and 1-stage reconstructed individual patient data meta-analysis (IPDMA) to compare outcomes between both groups. The primary outcome was 10-year all-cause mortality. Secondary outcomes included myocardial infarction (MI), stroke, and unplanned revascularization at 5 years. We performed individual patient data meta-analysis using published Kaplan-Meier curves to provide individual data points in coordinates and numbers at risk were used to increase the calibration accuracy of the reconstructed data. Shared frailty model or, when proportionality assumptions were not met, a restricted mean survival time model were fitted to compare outcomes between treatment groups. Of 583 articles retrieved, 5 RCTs were included. A total of 4,595 patients from these 5 RCTs were randomly assigned to PCI (n = 2,297) or CABG (n = 2,298). The cumulative 10-year all-cause mortality after PCI and CABG was 12.0% versus 10.6%, respectively (hazard ratio [HR] 1.093, 95% confidence interval [CI] 0.925 to 1.292; p = 0.296). PCI conferred similar time-to-MI (restricted mean survival time ratio 1.006, 95% CI 0.992 to 1.021, p=0.391) and stroke (restricted mean survival time ratio 1.005, 95% CI 0.998 to 1.013, p = 0.133) at 5 years. Unplanned revascularization was more frequent after PCI than CABG (HR 1.807, 95% CI 1.524 to 2.144, p <0.001) at 5 years. This meta-analysis using reconstructed participant-level time-to-event data showed no statistically significant difference in cumulative 10-year all-cause mortality between PCI versus CABG in the treatment of LMCAD.
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37
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Wang HY, Dou KF, Guan C, Xie L, Huang Y, Zhang R, Yang W, Wu Y, Yang Y, Qiao S, Gao R, Xu B. New Insights Into Long- Versus Short-Term Dual Antiplatelet Therapy Duration in Patients After Stenting for Left Main Coronary Artery Disease: Findings From a Prospective Observational Study. Circ Cardiovasc Interv 2022; 15:e011536. [PMID: 35582961 DOI: 10.1161/circinterventions.121.011536] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND The appropriate duration of dual antiplatelet therapy (DAPT) and risk-benefit ratio for long-term DAPT in patients with left main (LM) disease undergoing percutaneous coronary intervention remains uncertain. METHODS Four thousand five hundred sixty-one consecutive patients with stenting of LM disease at a single center from January 2004 to December 2016 were enrolled. Decision to discontinue or remain on DAPT after 12 months was left to an individualized decision-making based on treating physicians by weighing the patient's risks of ischemia versus bleeding and considering patient preference. The primary outcome was a composite of death, myocardial infarction, stent thrombosis, or stroke at 3 years. Key safety outcome was 3-year rate of Bleeding Academic Research Consortium 2, 3, or 5 bleeding. RESULTS Of 3865 patients free of ischemic and bleeding events at 12 months, 1727 (44.7%) remained on DAPT (mostly clopidogrel based [97.7%]) beyond 12 months after LM percutaneous coronary intervention. DAPT>12-month versus ≤12-month DAPT was associated with a significant reduced risk of 3-year primary outcome (2.6% versus 4.6%; adjusted hazard ratio: 0.59 [95% CI, 0.41-0.84]). The same trend was found for other ischemic end points: death (0.9% versus 3.0%; Plog-rank<0.001), cardiovascular death (0.5% versus 1.7%; Plog-rank=0.001), myocardial infarction (0.8% versus 1.9%; Plog-rank=0.005), and stent thrombosis (0.4% versus 1.1%; Plog-rank=0.017). The key safety end point was not significantly different between 2 regimens (1.8% versus 1.6%; adjusted hazard ratio: 1.07 [95% CI, 0.65-1.74]). The effect of DAPT>12 month on primary and key safety outcomes was consistent across clinical presentations, high bleeding risk, P2Y12 inhibitor, and LM bifurcation percutaneous coronary intervention approach. CONCLUSIONS In a large cohort of patients free from clinical events during the first year after LM percutaneous coronary intervention and at low apparent future bleeding risk, an individualized patient-tailored approach to longer duration (>12 month) of DAPT with aspirin plus a P2Y12 inhibitor (mostly clopidogrel) improved both composite and individual efficacy outcomes by reducing ischemic risk, without a concomitant increase in clinically relevant bleeding.
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Affiliation(s)
- Hao-Yu Wang
- Department of Cardiology, Cardiometabolic Medicine Center, Coronary Heart Disease Center (H.-Y.W., K.-F.D., R.Z., W.Y., Y.W., Y.Y., S.Q., R.G.), Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.,State Key Laboratory of Cardiovascular Disease, Beijing, China (H.-Y.W., K.-F.D., R.Z., Y.W., Y.Y.)
| | - Ke-Fei Dou
- Department of Cardiology, Cardiometabolic Medicine Center, Coronary Heart Disease Center (H.-Y.W., K.-F.D., R.Z., W.Y., Y.W., Y.Y., S.Q., R.G.), Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.,State Key Laboratory of Cardiovascular Disease, Beijing, China (H.-Y.W., K.-F.D., R.Z., Y.W., Y.Y.).,National Clinical Research Center for Cardiovascular Diseases, Beijing, China (K.-F.D., W.Y., Y.W., Y.Y., S.Q., R.G., B.X.)
| | - Changdong Guan
- Catheterization Laboratories (C.G., L.X., Y.H., B.X.), Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Lihua Xie
- Catheterization Laboratories (C.G., L.X., Y.H., B.X.), Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yunfei Huang
- Catheterization Laboratories (C.G., L.X., Y.H., B.X.), Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Rui Zhang
- Department of Cardiology, Cardiometabolic Medicine Center, Coronary Heart Disease Center (H.-Y.W., K.-F.D., R.Z., W.Y., Y.W., Y.Y., S.Q., R.G.), Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.,State Key Laboratory of Cardiovascular Disease, Beijing, China (H.-Y.W., K.-F.D., R.Z., Y.W., Y.Y.)
| | - Weixian Yang
- Department of Cardiology, Cardiometabolic Medicine Center, Coronary Heart Disease Center (H.-Y.W., K.-F.D., R.Z., W.Y., Y.W., Y.Y., S.Q., R.G.), Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.,National Clinical Research Center for Cardiovascular Diseases, Beijing, China (K.-F.D., W.Y., Y.W., Y.Y., S.Q., R.G., B.X.)
| | - Yongjian Wu
- Department of Cardiology, Cardiometabolic Medicine Center, Coronary Heart Disease Center (H.-Y.W., K.-F.D., R.Z., W.Y., Y.W., Y.Y., S.Q., R.G.), Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.,State Key Laboratory of Cardiovascular Disease, Beijing, China (H.-Y.W., K.-F.D., R.Z., Y.W., Y.Y.).,National Clinical Research Center for Cardiovascular Diseases, Beijing, China (K.-F.D., W.Y., Y.W., Y.Y., S.Q., R.G., B.X.)
| | - Yuejin Yang
- Department of Cardiology, Cardiometabolic Medicine Center, Coronary Heart Disease Center (H.-Y.W., K.-F.D., R.Z., W.Y., Y.W., Y.Y., S.Q., R.G.), Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.,State Key Laboratory of Cardiovascular Disease, Beijing, China (H.-Y.W., K.-F.D., R.Z., Y.W., Y.Y.).,National Clinical Research Center for Cardiovascular Diseases, Beijing, China (K.-F.D., W.Y., Y.W., Y.Y., S.Q., R.G., B.X.)
| | - Shubin Qiao
- Department of Cardiology, Cardiometabolic Medicine Center, Coronary Heart Disease Center (H.-Y.W., K.-F.D., R.Z., W.Y., Y.W., Y.Y., S.Q., R.G.), Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.,National Clinical Research Center for Cardiovascular Diseases, Beijing, China (K.-F.D., W.Y., Y.W., Y.Y., S.Q., R.G., B.X.)
| | - Runlin Gao
- Department of Cardiology, Cardiometabolic Medicine Center, Coronary Heart Disease Center (H.-Y.W., K.-F.D., R.Z., W.Y., Y.W., Y.Y., S.Q., R.G.), Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.,National Clinical Research Center for Cardiovascular Diseases, Beijing, China (K.-F.D., W.Y., Y.W., Y.Y., S.Q., R.G., B.X.)
| | - Bo Xu
- Catheterization Laboratories (C.G., L.X., Y.H., B.X.), Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.,National Clinical Research Center for Cardiovascular Diseases, Beijing, China (K.-F.D., W.Y., Y.W., Y.Y., S.Q., R.G., B.X.)
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38
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Zhang H, Zhao Z, Yao J, Zhao J, Hou T, Wang M, Xu Y, Wang B, Niu G, Sui Y, Song G, Wu Y. Prior percutaneous coronary intervention and outcomes in patients after coronary artery bypass grafting: a meta-analysis of 308,284 patients. Ther Adv Chronic Dis 2022; 13:20406223221078755. [PMID: 35586304 PMCID: PMC9109498 DOI: 10.1177/20406223221078755] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Accepted: 01/20/2022] [Indexed: 12/02/2022] Open
Abstract
Background: The association between prior percutaneous coronary intervention (PCI) and
prognosis after coronary artery bypass grafting (CABG) remains uncertain. We
aimed to evaluate the aforementioned association in a meta-analysis. Methods: PubMed, Cochrane’s Library, and Embase databases were searched for potential
studies. A random-effects model was used for the meta-analysis.
Meta-regression was performed to evaluate the influence of study
characteristics on the outcomes. Results: Thirty-six follow-up studies with 308,284 patients were included, and 40,892
(13.3%) patients had prior PCI. Pooled results showed that prior PCI was
associated with higher risks of early (in-hospital or within 1 month)
all-cause mortality [odds ratio (OR): 1.26, 95% confidence interval (CI):
1.11–1.44, p = 0.003; I2 = 64%]
and major adverse cardiovascular events (MACEs; OR: 1.36, 95% CI: 1.12–1.66,
p = 0.002, I2 = 79%), but
not with late (follow-up durations from 1 to 13 years) mortality (OR: 1.03,
95% CI: 0.95–1.13, p = 0.44,
I2 = 46%) or MACEs (OR: 1.03, 95% CI: 0.97–1.09,
p = 0.38, I2 = 0%).
Meta-regression showed that the study characteristics of patient number,
age, sex, diabetic status, and proportion of patients with prior PCI did not
affect the outcomes. Sensitivity analyses limited to multivariate studies
excluding patients with acute PCI failure showed similar results (early
mortality, OR: 1.25, p = 0.003; early MACE, OR: 1.50,
p = 0.001; late mortality, OR: 1.03,
p = 0.70). Conclusion: The current evidence, mostly from retrospective observational studies,
suggests that prior PCI is related to poor early clinical outcomes, but not
to late clinical outcomes, after CABG.
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Affiliation(s)
- Hongliang Zhang
- Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Zhenyan Zhao
- Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jing Yao
- Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jie Zhao
- Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Tao Hou
- Department of Cardiology, Cixian People's Hospital, Han Dan City, China
| | - Moyang Wang
- Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yanlu Xu
- Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Bincheng Wang
- Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Guannan Niu
- Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yonggang Sui
- Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Guangyuan Song
- Interventional Center of Valvular Heart Disease, Beijing Anzhen Hospital, Capital Medical University, Beijing Institute of Heart, Lung, and Blood Vessel Diseases, Anzhen road 2, Chaoyang District, Beijing 100029, China
| | - Yongjian Wu
- Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beilishi Road 167, Xicheng District, Beijing 100037, China
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39
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Stankovic G, Mehmedbegovic Z, Milasinovic D. Bifurcation Lesion Stenting. Interv Cardiol 2022. [DOI: 10.1002/9781119697367.ch16] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
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40
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Scudiero F, Muraca I, Migliorini A, Marcucci R, Pennesi M, Mazzolai L, Carrabba N, Marchionni N, Stefano P, Valenti R. Outcomes of Left Main Revascularization after Percutaneous Intervention or Bypass Surgery. J Interv Cardiol 2022; 2022:6496777. [PMID: 35494423 PMCID: PMC9019449 DOI: 10.1155/2022/6496777] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2021] [Revised: 03/20/2022] [Accepted: 03/23/2022] [Indexed: 11/20/2022] Open
Abstract
Background This study is aimed at comparing the clinical outcomes of unprotected left main coronary artery disease (ULMCAD) treatment with contemporary percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG) in a "real-world" population. Methods and Results Overall, 558 consecutive patients with ULMCAD (mean age 71 ± 9 years, male gender 81%) undergoing PCI or CABG were compared. The primary endpoint was the composite of death, nonfatal myocardial infarction, or stroke. Diabetes was present in 29% and acute coronary syndrome in 56%; mean EuroSCORE was 11 ± 8. High coronary complexity (SYNTAX score >32) was present in 50% of patients. The primary composite endpoint was similar after PCI and CABG up to 4 years (15.5 ± 3.1% vs. 17.1 ± 2.6%; p=0.585). The primary end point was also comparable in a two propensity score matched cohorts. Ischemia-driven revascularization was more frequently needed in PCI than in CABG (5.5% vs. 1.5%; p=0.010). By multivariate analysis, diabetes mellitus (HR 2.00; p=0.003) and EuroSCORE (HR 3.71; p < 0.001) were the only independent predictors associated with long-term outcome. Conclusions In a "real-world" population with ULMCAD, a contemporary revascularization strategy by PCI or CABG showed similar long-term clinical outcome regardless of the coronary complexity.
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Affiliation(s)
- Fernando Scudiero
- Medical Sciences Departement, Cardiology Unit, ASST Bergamo Est, Bolognini Hospital, Seriate, Bergamo, Italy
| | - Iacopo Muraca
- Division of Interventional Cardiology, Cardiothoracovascular Department, Careggi University Hospital, Florence, Italy
| | - Angela Migliorini
- Division of Interventional Cardiology, Cardiothoracovascular Department, Careggi University Hospital, Florence, Italy
| | - Rossella Marcucci
- Department of Clinical and Experimental Medicine, University of Florence, Florence, Italy
| | - Matteo Pennesi
- Division of Interventional Cardiology, Cardiothoracovascular Department, Careggi University Hospital, Florence, Italy
| | - Lapo Mazzolai
- Division of Cardiac Surgery Unit, Cardiothoracovascular Department, Careggi University Hospital, Florence, Italy
| | - Nazario Carrabba
- Division of Interventional Cardiology, Cardiothoracovascular Department, Careggi University Hospital, Florence, Italy
| | - Niccolò Marchionni
- Department of Clinical and Experimental Medicine, University of Florence, Florence, Italy
| | - Pierluigi Stefano
- Department of Clinical and Experimental Medicine, University of Florence, Florence, Italy
- Division of Cardiac Surgery Unit, Cardiothoracovascular Department, Careggi University Hospital, Florence, Italy
| | - Renato Valenti
- Division of Interventional Cardiology, Cardiothoracovascular Department, Careggi University Hospital, Florence, Italy
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41
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d'Entremont MA, Yagi R, Salia SJS, Zhang S, Shaban L, Bene-Alhasan Y, Papatheodorou S, Couture ÉL, Huynh T, Nguyen M, Hamaya R. The effect of diabetes on surgical versus percutaneous left main revascularization outcomes: a systematic review and meta-analysis. J Cardiothorac Surg 2022; 17:61. [PMID: 35365159 PMCID: PMC8973812 DOI: 10.1186/s13019-022-01795-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2021] [Accepted: 03/12/2022] [Indexed: 12/02/2022] Open
Abstract
Background The optimal method of coronary revascularization for diabetes mellitus (DM) patients with left main coronary artery disease (LMCAD) is controversial in the drug-eluting stent (DES) era. Methods We performed a systematic review and meta-analysis comparing DES-based percutaneous coronary intervention (PCI) to coronary artery bypass grafting (CABG) for LMCAD in DM patients and tested for effect measure modification (EMM) by diabetes for adverse events. We included all randomized controlled trials (RCTs) and observational studies comparing CABG to DES-based PCI including DM patients with LMCAD published up to March 1, 2021. We completed separate random-effects meta-analyses for four RCTs (4356 patients, mean follow-up of 4.9 years) and six observational studies (9360 patients, mean follow-up of 5.2 years). Results In RCTs among DM patients, DES-based PCI, compared to CABG, was associated with a 30% increased relative risk (RR) (RR 1.30, 95% CI 1.09–1.56, I2 = 0%), while among non-DM patients, there was a 25% increased relative risk (RR 1.25, 95% CI 1.07–1.44, I2 = 0%) for the composite endpoint of all-cause mortality, myocardial infarction, stroke, and unplanned revascularization (MACCE). There was no evidence of EMM (p-value for interaction = 0.70). The mean weighted SYNTAX score was 25.7. In observational studies, there was no difference between DES-based PCI and CABG for all-cause mortality in patients with DM (RR 1.13, 95% CI 0.91–1.40, I2 = 0%). Conclusions CABG was superior to PCI for LMCAD in RCTs in DM patients for MACCE. Heart teams may consider DM as one of the many components in the clinical decision-making process, but may not want to consider DM as a primary deciding factor between DES-based PCI and CABG for LMCAD with low to intermediate anatomical complexity in the other coronary arteries. Study registration CRD42021246931 (PROSPERO). Supplementary Information The online version contains supplementary material available at 10.1186/s13019-022-01795-w.
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Affiliation(s)
- Marc-André d'Entremont
- Division of Cardiology, Department of Medicine, Sherbrooke University Hospital Center (CHUS), 3001, 12e Avenue Nord, Sherbrooke, QC, J1H 5N4, Canada. .,Harvard T.H. Chan School of Public Health, Boston, MA, USA.
| | - Ryuichiro Yagi
- Harvard T.H. Chan School of Public Health, Boston, MA, USA.,Saiseikai Central Hospital, Tokyo, Japan
| | | | - Shuqi Zhang
- Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Lamyaa Shaban
- Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | | | | | - Étienne L Couture
- Division of Cardiology, Department of Medicine, Sherbrooke University Hospital Center (CHUS), 3001, 12e Avenue Nord, Sherbrooke, QC, J1H 5N4, Canada
| | - Thao Huynh
- McGill Health University Center, Montreal, QC, Canada
| | - Michel Nguyen
- Division of Cardiology, Department of Medicine, Sherbrooke University Hospital Center (CHUS), 3001, 12e Avenue Nord, Sherbrooke, QC, J1H 5N4, Canada
| | - Rikuta Hamaya
- Harvard T.H. Chan School of Public Health, Boston, MA, USA.,Brigham and Women's Hospital, Boston, MA, USA
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42
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Park S, Park SJ, Park DW. Percutaneous Coronary Intervention for Left Main Coronary Artery Disease: Present Status and Future Perspectives. JACC. ASIA 2022; 2:119-138. [PMID: 36339118 PMCID: PMC9627854 DOI: 10.1016/j.jacasi.2021.12.011] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Revised: 12/09/2021] [Accepted: 12/17/2021] [Indexed: 11/26/2022]
Abstract
For several decades, coronary artery bypass grafting has been regarded as the standard choice of revascularization for significant left main coronary artery (LMCA) disease. However, in conjunction with remarkable advancement of device technology and adjunctive pharmacology, percutaneous coronary intervention (PCI) offers a more expeditious approach with rapid recovery and is a safe and effective alternative in appropriately selected patients with LMCA disease. Several landmark randomized clinical trials showed that PCI with drug-eluting stents for LMCA disease is a safe option with similar long-term survival rates to coronary artery bypass grafting surgery, especially in those with low and intermediate anatomic risk. Although it is expected that the updated evidence from recent randomized clinical trials will determine the next guidelines for the foreseeable future, there are still unresolved and unmet issues of LMCA revascularization and PCI strategy. This paper provides a comprehensive review on the evolution and an update on the management of LMCA disease.
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Key Words
- BMS, bare-metal stent(s)
- CABG, coronary artery bypass grafting
- CAD, coronary artery disease
- DAPT, dual antiplatelet therapy
- DES, drug-eluting stent(s)
- DK, double-kissing
- FFR, fractional flow reserve
- IVUS, intravascular ultrasound
- LAD, left anterior descending artery
- LCX, left circumflex artery
- LMCA, left main coronary artery
- LVEF, left ventricular ejection fraction
- MACCE, major adverse cardiac or cerebrovascular events
- MI, myocardial infarction
- MLA, minimal lumen area
- PCI, percutaneous coronary intervention
- RCT, randomized clinical trial
- coronary artery bypass grafting
- iFR, instantaneous wave-free ratio
- left main coronary artery disease
- percutaneous coronary intervention
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Affiliation(s)
- Sangwoo Park
- Department of Cardiology, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, South Korea
| | - Seung-Jung Park
- Department of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Duk-Woo Park
- Department of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
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43
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Crea F. Percutaneous coronary intervention vs. coronary artery bypass graft: the saga continues. Eur Heart J 2022; 43:1273-1276. [PMID: 35362068 DOI: 10.1093/eurheartj/ehac118] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Filippo Crea
- Department of Cardiovascular Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.,Department of Cardiovascular and Pulmonary Sciences, Catholic University of the Sacred Heart, Rome, Italy
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44
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Kırat T. Fundamentals of percutaneous coronary bifurcation interventions. World J Cardiol 2022; 14:108-138. [PMID: 35432773 PMCID: PMC8968454 DOI: 10.4330/wjc.v14.i3.108] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Revised: 07/22/2021] [Accepted: 02/22/2022] [Indexed: 02/06/2023] Open
Abstract
Coronary bifurcation lesions (CBLs) account for 15%-20% of all percutaneous coronary interventions. The complex nature of these lesions is responsible for poorer procedural, early and late outcomes. This complex lesion subset has received great attention in the interventional cardiac community, and multiple stenting techniques have been developed. Of these, the provisional stenting technique is most often the default strategy; however, the elective double stenting (EDS) technique is preferred in certain subsets of complex CBLs. The double kissing crush technique may be the preferred EDS technique because of its efficacy and safety in comparative trials; however, this technique consists of many steps and requires training. Many new methods have recently been added to the EDS techniques to provide better stent scaffolding and to reduce early and late adverse outcomes. Intravascular imaging is necessary to determine the interventional strategy and postinterventional results. This review discusses the basic concepts, contemporary percutaneous interventional technical approaches, new methods, and controversial treatment issues of CBLs.
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Affiliation(s)
- Tamer Kırat
- Department of Cardiology, Yücelen Hospital, Muğla 48000, Turkey.
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45
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Malick WA, Soriano K, Stone GW. Sex-Based Differences in Revascularization Outcomes: Is It Time for a Dedicated Randomized Trial in Women? J Am Heart Assoc 2022; 11:e024281. [PMID: 35189696 PMCID: PMC9075096 DOI: 10.1161/jaha.121.024281] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Waqas A Malick
- The Zena and Michael A. Wiener Cardiovascular Institute Icahn School of Medicine at Mount Sinai New York NY
| | - Kevin Soriano
- The Zena and Michael A. Wiener Cardiovascular Institute Icahn School of Medicine at Mount Sinai New York NY
| | - Gregg W Stone
- The Zena and Michael A. Wiener Cardiovascular Institute Icahn School of Medicine at Mount Sinai New York NY.,Clinical Trials Center Cardiovascular Research Foundation New York NY
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46
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De Maria GL, Testa L, de la Torre Hernandez JM, Terentes-Printzios D, Emfietzoglou M, Scarsini R, Bedogni F, Spitzer E, Banning A. A multi-center, international, randomized, 2-year, parallel-group study to assess the superiority of IVUS-guided PCI versus qualitative angio-guided PCI in unprotected left main coronary artery (ULMCA) disease: Study protocol for OPTIMAL trial. PLoS One 2022; 17:e0260770. [PMID: 34995276 PMCID: PMC8740965 DOI: 10.1371/journal.pone.0260770] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2021] [Accepted: 11/02/2021] [Indexed: 12/28/2022] Open
Abstract
Background Percutaneous coronary intervention (PCI) is used increasingly for revascularization of unprotected left main coronary artery (LMCA) disease. Observational studies and subgroup analyses from clinical trials, have suggested a possible benefit from the use of intravascular ultrasound (IVUS) guidance when performing unprotected LMCA PCI. However, the value of imaging with IVUS has never been proven in an appropriately powered randomized clinical trial. The OPtimizaTIon of Left MAin PCI With IntravascuLar Ultrasound (OPTIMAL) trial has been designed to establish whether IVUS-guided PCI optimization on LMCA is associated with superior clinical outcomes when compared with standard qualitative angiography-guided PCI. Methods The OPTIMAL trial is a randomized, multicenter, international study designed to enroll a total of 800 patients undergoing PCI for unprotected LMCA disease. Patients will be randomized in a 1:1 fashion to IVUS-guided PCI versus angiogram-guided PCI. In patients allocated to the angiogram-guided arm, use of IVUS is discouraged, unless there are safety concerns. In patients allocated to the IVUS guidance arm, pre-procedural IVUS assessment is highly recommended, whilst post-procedural IVUS assessment is mandatory to confirm appropriate stenting result and/or to guide stent result optimization, according to predefined criteria. Patients will be followed up to 2 years after the index procedure. The primary outcome measure is the Academic Research Consortium (ARC) patient-oriented composite endpoint (PoCE) which includes all-cause death, any stroke, any myocardial infarction and any repeat revascularization at 2 years follow-up. Discussion The OPTIMAL trial aims to provide definitive evidence about the clinical impact of IVUS-guidance during PCI to an unprotected LMCA. It is anticipated by the investigators, that an IVUS-guided strategy will be associated with less clinical events compared to a strategy guided by angiogram alone. Trial registration ClinicalTrials.gov: NCT04111770. Registered on October 1, 2019.
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Affiliation(s)
- Giovanni Luigi De Maria
- Heart Centre, John Radcliffe Hospital, Oxford University Hospitals, NHS Foundation Trust, Oxford, United Kingdom
| | - Luca Testa
- Coronary Revascularisation Unit, IRCCS Policlinico S. Donato, San Donato Milanese, Milan, Italy
| | | | - Dimitrios Terentes-Printzios
- Heart Centre, John Radcliffe Hospital, Oxford University Hospitals, NHS Foundation Trust, Oxford, United Kingdom
| | - Maria Emfietzoglou
- Heart Centre, John Radcliffe Hospital, Oxford University Hospitals, NHS Foundation Trust, Oxford, United Kingdom
| | - Roberto Scarsini
- Heart Centre, John Radcliffe Hospital, Oxford University Hospitals, NHS Foundation Trust, Oxford, United Kingdom
| | - Francesco Bedogni
- Coronary Revascularisation Unit, IRCCS Policlinico S. Donato, San Donato Milanese, Milan, Italy
| | - Ernest Spitzer
- European Cardiovascular Research Institute, Rotterdam, The Netherlands
- Department of Cardiology, Thoraxcenter, Erasmus Medical Centre, Rotterdam, The Netherlands
| | - Adrian Banning
- Heart Centre, John Radcliffe Hospital, Oxford University Hospitals, NHS Foundation Trust, Oxford, United Kingdom
- * E-mail:
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Kayaert P, Coeman M, Hanet C, Claeys MJ, Desmet W, De Pauw M, Haine S, Taeymans Y. Practice and long-term outcome of unprotected left main PCI: real-world data from a nationwide registry. Acta Cardiol 2022; 77:51-58. [PMID: 33683172 DOI: 10.1080/00015385.2021.1876402] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
BACKGROUND Percutaneous coronary intervention (PCI) is increasingly performed in significant left main (LM) lesions. Left untreated, the prognosis is poor, but PCI and coronary bypass surgery (CABG) behold risks as well. Additional long-term outcome data might guide future treatment decisions. METHODS Between 2012 and 2019, all 6783 patients who underwent LM PCI were prospectively enrolled in a national registry. Patients with prior CABG or prior LM PCI, and patients presenting in cardiogenic shock or after out-of-hospital cardiac arrest were excluded. From the remaining 5284 patients, baseline and procedural data as well as long-term survival were assessed. RESULTS The annual rate of LM PCI increased from 422 (2.2% of PCIs) in 2012 to 868 in 2018 (3.0%). By 2018, 71% of the interventional cardiologists performed at least 1 LM PCI a year, though only 5 on average. Use of transradial access (TRA) in LM PCI increased from 20.4% in 2012 to 59.5% in 2019. All-cause mortality was 6.0% at 30 days and 18.5% at a mean follow-up of 33.5 months. Independent predictors of higher long-term mortality were older age, diabetes, multivessel disease, an urgent indication, a suboptimal angiographical result, and non-exclusive use of drug-eluting stents. TRAand higher operator and centre LM PCI experience were independent predictors of a lower long-term mortality. CONCLUSION LM PCI is associated with high short- and long-term mortality. Use of TRA and higher expertise in LM PCI were associated with better survival.
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Affiliation(s)
- Peter Kayaert
- Department of Cardiology, Universitair Ziekenhuis Gent, Ghent, Belgium
| | - Mathieu Coeman
- Department of Cardiology, Jan Yperman Ziekenhuis, Ypres, Belgium
| | - Claude Hanet
- Department of Cardiology, Clinique Universitaire de l’université catholique de Louvain, Namur, Belgium
| | - Marc J. Claeys
- Department of Cardiology, Antwerp University Hospital, Antwerp, Belgium
- Department of Cardiovascular Diseases, University of Antwerp, Antwerp, Belgium
| | - Walter Desmet
- Department of Cardiovascular Diseases, University Hospital Leuven, Leuven, Belgium
| | - Michel De Pauw
- Department of Cardiology, Universitair Ziekenhuis Gent, Ghent, Belgium
| | - Steven Haine
- Department of Cardiology, Antwerp University Hospital, Antwerp, Belgium
- Department of Cardiovascular Diseases, University of Antwerp, Antwerp, Belgium
| | - Yves Taeymans
- Department of Cardiology, Universitair Ziekenhuis Gent, Ghent, Belgium
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Lawton JS, Tamis-Holland JE, Bangalore S, Bates ER, Beckie TM, Bischoff JM, Bittl JA, Cohen MG, DiMaio JM, Don CW, Fremes SE, Gaudino MF, Goldberger ZD, Grant MC, Jaswal JB, Kurlansky PA, Mehran R, Metkus TS, Nnacheta LC, Rao SV, Sellke FW, Sharma G, Yong CM, Zwischenberger BA. 2021 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. J Am Coll Cardiol 2022; 79:e21-e129. [PMID: 34895950 DOI: 10.1016/j.jacc.2021.09.006] [Citation(s) in RCA: 783] [Impact Index Per Article: 261.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
AIM The guideline for coronary artery revascularization replaces the 2011 coronary artery bypass graft surgery and the 2011 and 2015 percutaneous coronary intervention guidelines, providing a patient-centric approach to guide clinicians in the treatment of patients with significant coronary artery disease undergoing coronary revascularization as well as the supporting documentation to encourage their use. METHODS A comprehensive literature search was conducted from May 2019 to September 2019, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Collaboration, CINHL Complete, and other relevant databases. Additional relevant studies, published through May 2021, were also considered. STRUCTURE Coronary artery disease remains a leading cause of morbidity and mortality globally. Coronary revascularization is an important therapeutic option when managing patients with coronary artery disease. The 2021 coronary artery revascularization guideline provides recommendations based on contemporary evidence for the treatment of these patients. The recommendations present an evidence-based approach to managing patients with coronary artery disease who are being considered for coronary revascularization, with the intent to improve quality of care and align with patients' interests.
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Lawton JS, Tamis-Holland JE, Bangalore S, Bates ER, Beckie TM, Bischoff JM, Bittl JA, Cohen MG, DiMaio JM, Don CW, Fremes SE, Gaudino MF, Goldberger ZD, Grant MC, Jaswal JB, Kurlansky PA, Mehran R, Metkus TS, Nnacheta LC, Rao SV, Sellke FW, Sharma G, Yong CM, Zwischenberger BA. 2021 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation 2022; 145:e18-e114. [PMID: 34882435 DOI: 10.1161/cir.0000000000001038] [Citation(s) in RCA: 273] [Impact Index Per Article: 91.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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Prashar A, Shim SJ, Esber Y, Epstein J, Maheepala K, Rees D. Cardiovascular complications of mantle field radiation: a case series. Eur Heart J Case Rep 2022; 6:ytac017. [PMID: 35174307 PMCID: PMC8846184 DOI: 10.1093/ehjcr/ytac017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2021] [Revised: 07/26/2021] [Accepted: 01/10/2022] [Indexed: 11/30/2022]
Abstract
Background Mantle field radiotherapy has been known to cause cardiovascular complications even years after therapy. Complications include pericardial disease, coronary artery disease, and conduction abnormalities. Case summary We present a case series of two patients who developed cardiovascular complications years after receiving mantle radiation. Patient 1 is a 52-year-old man who presented with symptoms of heart failure. He had a neurostimulator which precluded him from cardiac magnetic resonance imaging. Haemodynamic findings on right heart catheterization raised suspicion for constrictive pericarditis and pericardiectomy was performed. Histopathological analysis reported dense, sclerotic fibrous tissue consistent with radiation-related changes. Patient 2 is a 37-year-old man with a 2-month history of chest pain and exertional dyspnoea who was admitted for management of coronary artery disease. Coronary angiography demonstrated bilateral subclavian artery stenosis and an elevated left ventricular end-diastolic pressure (50 mmHg). He had bilateral percutaneous subclavian artery stenting. Both patients had complete resolution of symptoms on follow-up. Discussion Our case series emphasizes the need for an index of suspicion for radiation-related cardiovascular changes in patients who have a history of mantle radiation, especially in younger patients. This was especially pertinent in the case of our first patient who presented a diagnostic challenge due to certain patient factors. Our second patient is a case of subclavian artery stenosis which is less frequently reported as a complication of mantle radiation in the literature.
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Affiliation(s)
- Abhisheik Prashar
- Department of Cardiology, St George Hospital, Sydney, NSW 2217, Australia
- St George and Sutherland Clinical School, UNSW Medicine, UNSW Sydney, Sydney, Australia
| | - So-Jung Shim
- St George and Sutherland Clinical School, UNSW Medicine, UNSW Sydney, Sydney, Australia
| | - Yamema Esber
- St George and Sutherland Clinical School, UNSW Medicine, UNSW Sydney, Sydney, Australia
| | - Jessica Epstein
- Department of Cardiology, St George Hospital, Sydney, NSW 2217, Australia
| | - Krishan Maheepala
- Department of Cardiology, St George Hospital, Sydney, NSW 2217, Australia
- St George and Sutherland Clinical School, UNSW Medicine, UNSW Sydney, Sydney, Australia
| | - David Rees
- Department of Cardiology, St George Hospital, Sydney, NSW 2217, Australia
- St George and Sutherland Clinical School, UNSW Medicine, UNSW Sydney, Sydney, Australia
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