RESUMEN
BACKGROUND: Little is known about the underlying factors contributing to unfavourable clinical outcomes in patients with diabetes mellitus (DM) complicated by new-onset acute myocardial infarction (AMI). The aim of this study was to investigate the impact of DM on the pathophysiologic features and prognosis of patients with new-onset AMI following successful revascularization by utilizing cardiac magnetic resonance (CMR). METHODS: Consecutive patients diagnosed with new-onset AMI between June 2022 and January 2024 were included. All patients underwent culprit vessel revascularization upon admission and CMR imaging 3-7 days later. The primary clinical endpoint of this study was the occurrence of major adverse cardiac and cerebrovascular events (MACCEs), for which the average follow-up was 10 months. RESULTS: A total of 72 patients were divided into a DM group (n = 23) and a non-DM group (n = 49). Multivariate logistic regression analysis revealed that DM was an independent risk factor for the occurrence of microvascular obstruction. Multivariate linear regression analysis found that DM was the influencing factor of global radial strain (B = -4.107, t = -2.328, p = 0.023), while fasting blood glucose influenced infarct segment myocardial radial strain (B = -0.622, t = -2.032, p = 0.046). DM independently contributed to the risk of MACCEs following successful revascularization in patients with AMI (p < 0.05). CONCLUSION: Comprehensive phenotypic characterization of myocardial injury and microcirculatory status could enable reliable identification of high-risk MACCEs in DM patients with new-onset AMI following successful revascularization.
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Infarto del Miocardio , Humanos , Masculino , Femenino , Persona de Mediana Edad , Estudios Prospectivos , Infarto del Miocardio/diagnóstico por imagen , Infarto del Miocardio/fisiopatología , Pronóstico , Anciano , Diabetes Mellitus/epidemiología , Diabetes Mellitus/fisiopatología , Revascularización Miocárdica/estadística & datos numéricos , Factores de Riesgo , Imagen por Resonancia Magnética , Imagen por Resonancia Cinemagnética/métodosRESUMEN
OBJECTIVE: To assess long-term clinical outcomes and factors associated with target vessel revascularisation in patients with deferred revascularisation based on negative fractional flow reserve and negative instantaneous wave-free ratio. METHODS: The longitudinal, retrospective study was conducted from July 1, 2020, to January 1, 2022, at the Aga Khan University Hospital, Karachi, and comprised medical records from January 2012 to January 2020 of patients with deferred revascularisation having intermediate to severe coronary lesions on coronary angiogram and had negative fractional flow reserve >0.80 or instantaneous wave-free ratio >0.89 and had not undergone immediate or planned revascularisation on the basis of negative physiological assessment. Data was collected from the institutional records, while final follow-up was taken by reviewing the medical records or telephonic interviews regarding any major adverse cardiac event after the index procedure. Data was analysed using Stata 14.2. RESULTS: Of the 345 patients, 245(71%) were males. The overall mean age was 62±11 years. There were 194(56%) patients who presented with stable angina and 151(44%) presented with acute coronary syndrome. Mean fractional flow reserve was 0.87±0.04 and mean instantaneous wave-free ratio was 0.93±0.03. Multivessel disease was present in 223(65%) patients. Median follow-up period was 29 months (IQR: 24-36 months). Major adverse cardiovascular events occurred in 22(6%) patients, and target vessel revascularisation was required in 11(3%). Diabetes and percentage of stenosis were found to be independent predictors of major adverse cardiovascular events (p<0.05). CONCLUSIONS: Deferral of revascularisation and opting for medical treatment for coronary artery stenosis with higher fractional flow reserve or instantaneous wave-free ratio could be considered a safe and reasonable strategy.
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Angiografía Coronaria , Reserva del Flujo Fraccional Miocárdico , Revascularización Miocárdica , Humanos , Reserva del Flujo Fraccional Miocárdico/fisiología , Masculino , Femenino , Persona de Mediana Edad , Pakistán/epidemiología , Estudios Retrospectivos , Anciano , Revascularización Miocárdica/métodos , Revascularización Miocárdica/estadística & datos numéricos , Enfermedad de la Arteria Coronaria/cirugía , Enfermedad de la Arteria Coronaria/fisiopatología , Estudios Longitudinales , Estenosis Coronaria/fisiopatología , Estenosis Coronaria/cirugía , Síndrome Coronario Agudo/cirugía , Síndrome Coronario Agudo/fisiopatología , Angina Estable/cirugía , Angina Estable/fisiopatología , Resultado del Tratamiento , Intervención Coronaria Percutánea/métodosRESUMEN
Background and Objectives: The progression of global warming results in an increased exposure to extreme heat, leading to exaggeration of preexisting diseases and premature deaths. The aim of the study was to present possible risk factors for all-cause long-term mortality in patients who underwent surgical revascularization, including an assessment of the influence of ambient temperature exposure. Materials and Methods: Retrospective analysis included 153 (123 (80%) males and 30 (20%) females) patients who underwent off-pump revascularization and were followed for a median time of 2533 (1035-3250) days. The demographical, clinical data and ambient temperature exposure were taken into analysis for prediction of all-cause mortality. Individual exposure was calculated based on the place of habitation. Results: In the multivariate logistic regression model with backward stepwise elimination method, risk factors such as dyslipidaemia (p = 0.001), kidney disease (p = 0.005), age (p = 0.006), and body mass index (p = 0.007) were found to be significant for late mortality prediction. In addition to traditional factors, environmental characteristics, including tropical nights (p = 0.043), were revealed to be significant. Conclusions: High night-time ambient temperatures known as tropical nights may be regarded as additional long-term mortality risk factor after surgical revascularization.
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Temperatura , Humanos , Masculino , Femenino , Persona de Mediana Edad , Estudios Retrospectivos , Anciano , Factores de Riesgo , Revascularización Miocárdica/estadística & datos numéricos , Revascularización Miocárdica/métodos , Revascularización Miocárdica/efectos adversos , Modelos Logísticos , Enfermedad de la Arteria Coronaria/cirugía , Enfermedad de la Arteria Coronaria/mortalidad , Enfermedad de la Arteria Coronaria/complicaciones , Índice de Masa CorporalRESUMEN
BACKGROUND: Coronary artery disease (CAD) is a common underlying cause of de novo heart failure (HF) and is associated with poor outcome despite advances in medical therapy. There are no data clearly supporting coronary angiogram (CVG) and revascularization in this setting. METHODS: We analysed a nationwide, comprehensive, and universal administrative database of consecutive patients for the first time admitted in hospital for HF, without a history of CAD, who survived 30 days after index admission from 2015 to 2019 in Italy. Enrolled patients were classified into subjects who did not undergo CVG; those who underwent CVG without coronary revascularization; those who underwent percutaneous coronary intervention (PCI); and those who underwent coronary artery bypass grafting (CABG). RESULTS: During the study period, 342,090 patients were hospitalized for the first time due to HF and survived 30 days after admission, in Italy. Among them, 30,806 (9.0%) patients underwent CVG without undergoing coronary revascularization, 5855 (1.7%) underwent PCI and 1594 (0.5%) underwent CABG. After adjusting for age, gender and comorbidity, the hazard ratio (HR) for 1-year all-cause mortality in patients undergoing CVG vs no CVG were 0.56 (p < 0.0001), 0.66 (p < 0.0001) and 0.83 (p = 0.020) for CVG, PCI and CABG patients, respectively. When considering the re-hospitalization for HF as the outcome, using death as a competing risk, after multiple corrections, CVG (HR = 0.80; p < 0.0001) and CABG (HR = 0.73; p < 0.0002) were protective versus No CVG, but not PCI (HR = 1.02; p = 0.642). CONCLUSIONS: This study provides evidence that CVG and coronary revascularization may be beneficial for patients with de novo HF.
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Angiografía Coronaria , Insuficiencia Cardíaca , Intervención Coronaria Percutánea , Humanos , Masculino , Femenino , Italia/epidemiología , Angiografía Coronaria/métodos , Anciano , Insuficiencia Cardíaca/epidemiología , Persona de Mediana Edad , Pronóstico , Intervención Coronaria Percutánea/métodos , Intervención Coronaria Percutánea/tendencias , Enfermedad de la Arteria Coronaria/cirugía , Enfermedad de la Arteria Coronaria/diagnóstico por imagen , Anciano de 80 o más Años , Estudios Retrospectivos , Revascularización Miocárdica/métodos , Revascularización Miocárdica/estadística & datos numéricos , Revascularización Miocárdica/tendencias , Puente de Arteria Coronaria/tendencias , Puente de Arteria Coronaria/métodosRESUMEN
This cross-sectional study assesses the generalizability of the American College of Cardiology/American Heart Association/Society for Cardiovascular Angiography and Interventions (ACC/AHA/SCAI) guideline by examining the representation of older adults in studies cited in the guideline.
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Enfermedad de la Arteria Coronaria , Revascularización Miocárdica , Guías de Práctica Clínica como Asunto , Humanos , Anciano , Masculino , Femenino , Estados Unidos , Enfermedad de la Arteria Coronaria/cirugía , Revascularización Miocárdica/normas , Revascularización Miocárdica/estadística & datos numéricos , Revascularización Miocárdica/métodos , American Heart Association , Persona de Mediana Edad , Anciano de 80 o más AñosRESUMEN
The incidence of acute myocardial infarction is increasing in younger age groups, with differences in treatment and outcomes based on gender. ST-elevation myocardial infarction (STEMI) in young adults, however, is incompletely understood as most of the current studies were performed in homogenous populations, did not focus on STEMI, and lack direct comparisons with older adults. We performed a retrospective observational study using the Statewide Planning And Research Cooperative System for all admissions in New York State with a principal diagnosis of STEMI from 2011 to 2018. There were 58,083 STEMIs with the majority being male (68.2%) and non-Hispanic White (64.8%), with an average age of 63.9 ± 13.9 years. Of these, 8,494 (14.6%) occurred in patients aged <50 years. The proportion of STEMIs in women increased with age, from 19.2% in the <50-year-old age group to 48.9% in the ≥70-year-old age group. Young adults with STEMI had greater prevalence of obesity, current tobacco use, other substance use, and major psychiatric disorders, were more likely to receive revascularization, and had lower 1-year mortality than older age groups. Revascularization was associated with at least a 3 times lower odds ratio of 1-year mortality in all age groups. In conclusion, young adults with STEMI had a unique set of risk factors and co-morbidities and were more likely to undergo revascularization than older age groups. In all age groups, female gender was associated with a higher burden of co-morbidities, decreased use of revascularization, and increased 1-year mortality.
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Revascularización Miocárdica , Infarto del Miocardio con Elevación del ST , Humanos , Masculino , Femenino , Infarto del Miocardio con Elevación del ST/epidemiología , Infarto del Miocardio con Elevación del ST/cirugía , Persona de Mediana Edad , Estudios Retrospectivos , Factores de Riesgo , Anciano , Revascularización Miocárdica/estadística & datos numéricos , Factores de Edad , New York/epidemiología , Adulto , IncidenciaRESUMEN
BACKGROUND: Metabolic bariatric surgery (MBS) not only leads to a durable weight loss but also lowers mortality, and reduces cardiovascular risks. OBJECTIVES: The current study aims to investigate the association of bariatric metabolic surgery (BMS) with admissions for acute myocardial infarction (AMI), including ST-elevation myocardial infarction (STEMI) and non-ST-elevation myocardial infarction (NSTEMI), as well as, coronary revascularization procedures, including percutaneous coronary intervention (PCI), coronary artery bypass graft (CABG), and thrombolysis. SETTING: The National Inpatient Sample (NIS) database. METHODS: The NIS data from 2016 to 2020 were analyzed. A propensity score matching in a 1:1 ratio was performed to match patients with history of MBS with non-MBS group. RESULTS: Two hundred thirty-three thousand seven hundred twenty-nine patients from the non-MBS group were matched with 233,729 patients with history of MBS. The MBS group had about 52% reduced odds of admission for AMI compared to the non-MBS group (adjusted odd ratio: .477, 95% confidence interval: .454-.502, P value <.001). In addition, the odds of STEMI and NSEMI were significantly lower in the MBS group in comparison to the non-MBS group. Also, the MBS group had significantly lower odds of CABG, PCI, and thrombolysis compared to the non-MBS group. In addition, in patients with AMI, MBS was associated with lower in-hospital mortality (adjusted odd ratio: .627, 95% confidence interval: .469-.839, P value = .004), length of hospital stays, and total charges. CONCLUSIONS: History of MBS is significantly associated with reduced risk of admission for AMI including STEMI and NSTEMI, as well as the, need for coronary revascularization such as PCI and CABG.
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Cirugía Bariátrica , Infarto del Miocardio , Puntaje de Propensión , Humanos , Masculino , Femenino , Persona de Mediana Edad , Cirugía Bariátrica/estadística & datos numéricos , Adulto , Infarto del Miocardio/epidemiología , Infarto del Miocardio/cirugía , Estados Unidos/epidemiología , Intervención Coronaria Percutánea/estadística & datos numéricos , Revascularización Miocárdica/estadística & datos numéricos , Anciano , Puente de Arteria Coronaria/estadística & datos numéricos , Infarto del Miocardio con Elevación del ST/cirugía , Infarto del Miocardio con Elevación del ST/mortalidad , Infarto del Miocardio con Elevación del ST/epidemiología , Estudios RetrospectivosRESUMEN
This Viewpoint discusses the unequal representation of women in coronary revascularization trials in the US, its negative effects on the cardiovascular health of both sexes, and potential mechanisms to ensure appropriate representation of women moving forward.
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Revascularización Miocárdica , Humanos , Femenino , Revascularización Miocárdica/métodos , Revascularización Miocárdica/estadística & datos numéricos , Ensayos Clínicos como Asunto , MasculinoRESUMEN
Recent trials suggested immediate complete revascularization (ICR) as a safe alternative to staged complete revascularization (SCR), but the impact of the respective percutaneous coronary intervention strategies between on- versus off-hours is unclear. On-hours was defined as an index revascularization performed between 8:00 a.m. and 6:00 p.m., Monday to Friday, or else the procedure was defined as performed during off-hours. The primary end point consisted of a composite of all-cause mortality, myocardial infarction, unplanned ischemia-driven revascularization, and cerebrovascular events at 1-year follow-up. We used Cox regression models to relate randomized treatment with study end points. We evaluated multiplicative and additive interactions between on- versus off-hours and randomized treatment. The BIOVASC (Percutaneous Complete Revascularization Strategies Using Sirolimus Eluting Biodegradable Polymer Coated Stents in Patients Presenting With Acute Coronary Syndromes and Multivessel Disease) trial enrolled 1,097 and 428 patients during on- and off-hours, respectively. Patients randomized during off-hours were more likely to present with ST-segment elevation myocardial infarction (66.4% vs 29.5%, p <0.001). The composite primary outcome occurred in 8.4% and 10.1% of patients randomized to ICR and SCR, respectively, during on-hours (hazard ratio 0.80, 95% confidence interval 0.54 to 1.19). During off-hours, the primary composite outcome occurred in 5.4% and 7.7% in ICR and SCR (0.69, 95% confidence interval 0.32 to 1.46) with no evidence of a differential effect (interaction pmultiplicative = 0.70, padditive = 0.56). No differential effect was found between treatment allocation and on- versus off-hours in any of the secondary outcomes. In conclusion, no differential treatment effect was found when comparing ICR versus SCR in patients presenting with acute coronary syndrome and multivessel disease during on- or off-hours.
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Stents Liberadores de Fármacos , Intervención Coronaria Percutánea , Humanos , Masculino , Femenino , Intervención Coronaria Percutánea/métodos , Persona de Mediana Edad , Anciano , Factores de Tiempo , Síndrome Coronario Agudo/cirugía , Síndrome Coronario Agudo/terapia , Infarto del Miocardio con Elevación del ST/cirugía , Infarto del Miocardio con Elevación del ST/terapia , Revascularización Miocárdica/métodos , Revascularización Miocárdica/estadística & datos numéricos , Enfermedad de la Arteria Coronaria/cirugía , Resultado del Tratamiento , Sirolimus/uso terapéutico , Estudios de SeguimientoRESUMEN
Importance: Clinical outcomes after acute coronary syndromes (ACS) or percutaneous coronary interventions (PCIs) in people living with HIV have not been characterized in sufficient detail, and extant data have not been synthesized adequately. Objective: To better characterize clinical outcomes and postdischarge treatment of patients living with HIV after ACS or PCIs compared with patients in an HIV-negative control group. Data Sources: Ovid MEDLINE, Embase, and Web of Science were searched for all available longitudinal studies of patients living with HIV after ACS or PCIs from inception until August 2023. Study Selection: Included studies met the following criteria: patients living with HIV and HIV-negative comparator group included, patients presenting with ACS or undergoing PCI included, and longitudinal follow-up data collected after the initial event. Data Extraction and Synthesis: Data extraction was performed following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) statement. Clinical outcome data were pooled using a random-effects model meta-analysis. Main Outcome and Measures: The following clinical outcomes were studied: all-cause mortality, major adverse cardiovascular events, cardiovascular death, recurrent ACS, stroke, new heart failure, total lesion revascularization, and total vessel revascularization. The maximally adjusted relative risk (RR) of clinical outcomes on follow-up comparing patients living with HIV with patients in control groups was taken as the main outcome measure. Results: A total of 15 studies including 9499 patients living with HIV (pooled proportion [range], 76.4% [64.3%-100%] male; pooled mean [range] age, 56.2 [47.0-63.0] years) and 1â¯531â¯117 patients without HIV in a control group (pooled proportion [range], 61.7% [59.7%-100%] male; pooled mean [range] age, 67.7 [42.0-69.4] years) were included; both populations were predominantly male, but patients living with HIV were younger by approximately 11 years. Patients living with HIV were also significantly more likely to be current smokers (pooled proportion [range], 59.1% [24.0%-75.0%] smokers vs 42.8% [26.0%-64.1%] smokers) and engage in illicit drug use (pooled proportion [range], 31.2% [2.0%-33.7%] drug use vs 6.8% [0%-11.5%] drug use) and had higher triglyceride (pooled mean [range], 233 [167-268] vs 171 [148-220] mg/dL) and lower high-density lipoprotein-cholesterol (pooled mean [range], 40 [26-43] vs 46 [29-46] mg/dL) levels. Populations with and without HIV were followed up for a pooled mean (range) of 16.2 (3.0-60.8) months and 11.9 (3.0-60.8) months, respectively. On postdischarge follow-up, patients living with HIV had lower prevalence of statin (pooled proportion [range], 53.3% [45.8%-96.1%] vs 59.9% [58.4%-99.0%]) and ß-blocker (pooled proportion [range], 54.0% [51.3%-90.0%] vs 60.6% [59.6%-93.6%]) prescriptions compared with those in the control group, but these differences were not statistically significant. There was a significantly increased risk among patients living with HIV vs those without HIV for all-cause mortality (RR, 1.64; 95% CI, 1.32-2.04), major adverse cardiovascular events (RR, 1.11; 95% CI, 1.01-1.22), recurrent ACS (RR, 1.83; 95% CI, 1.12-2.97), and admissions for new heart failure (RR, 3.39; 95% CI, 1.73-6.62). Conclusions and Relevance: These findings suggest the need for attention toward secondary prevention strategies to address poor outcomes of cardiovascular disease among patients living with HIV.
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Síndrome Coronario Agudo , Infecciones por VIH , Intervención Coronaria Percutánea , Humanos , Infecciones por VIH/complicaciones , Infecciones por VIH/epidemiología , Síndrome Coronario Agudo/cirugía , Síndrome Coronario Agudo/epidemiología , Intervención Coronaria Percutánea/estadística & datos numéricos , Masculino , Persona de Mediana Edad , Femenino , Resultado del Tratamiento , Revascularización Miocárdica/estadística & datos numéricos , AdultoRESUMEN
Cardiogenic shock after acute myocardial infarction (AMI-CS) carries significant mortality despite advances in revascularization and mechanical circulatory support. We sought to identify the process-based and structural characteristics of centers with lower mortality in AMI-CS. We analyzed 16,337 AMI-CS cases across 440 centers enrolled in the National Cardiovascular Data Registry's Chest Pain-MI Registry, a retrospective cohort database, between January 1, 2015, and December 31, 2018. Centers were stratified across tertiles of risk-adjusted in-hospital mortality rate (RAMR) for comparison. Risk-adjusted multivariable logistic regression was also performed to identify hospital-level characteristics associated with decreased mortality. The median participant age was 66 (interquartile range 57 to 75) years, and 33.0% (n = 5,390) were women. The median RAMR was 33.4% (interquartile range 26.0% to 40.0%) and ranged from 26.9% to 50.2% across tertiles. Even after risk adjustment, lower-RAMR centers saw patients with fewer co-morbidities. Lower-RAMR centers performed more revascularization (92.8% vs 90.6% vs 85.9%, p <0.001) and demonstrated better adherence to associated process measures. Left ventricular assist device capability (odds ratio [OR] 0.78 [0.67 to 0.92], p = 0.002), more frequent revascularization (OR 0.93 [0.88 to 0.98], p = 0.006), and higher AMI-CS volume (OR 0.95 [0.91 to 0.99], p = 0.009) were associated with lower in-hospital mortality. However, several such characteristics were not more frequently observed at low-RAMR centers, despite potentially reflecting greater institutional experience or resources. This may reflect the heterogeneity of AMI-CS even after risk adjustment. In conclusion, low-RAMR centers do not necessarily exhibit factors associated with decreased mortality in AMI-CS, which may reflect the challenges in performing outcomes research in this complex population.
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Mortalidad Hospitalaria , Infarto del Miocardio , Sistema de Registros , Choque Cardiogénico , Humanos , Femenino , Masculino , Choque Cardiogénico/etiología , Choque Cardiogénico/mortalidad , Choque Cardiogénico/terapia , Persona de Mediana Edad , Anciano , Infarto del Miocardio/complicaciones , Infarto del Miocardio/mortalidad , Estudios Retrospectivos , Estados Unidos/epidemiología , Hospitales de Alto Volumen , Revascularización Miocárdica/estadística & datos numéricosRESUMEN
BACKGROUND AND AIMS: Older patients with non-ST-elevation acute coronary syndrome (NSTEACS) are less likely to receive guideline-recommended care including coronary angiography and revascularization. Evidence-based recommendations regarding interventional management strategies in this patient cohort are scarce. This meta-analysis aimed to assess the impact of routine invasive vs. conservative management of NSTEACS by using individual patient data (IPD) from all available randomized controlled trials (RCTs) including older patients. METHODS: MEDLINE, Web of Science and Scopus were searched between 1 January 2010 and 11 September 2023. RCTs investigating routine invasive and conservative strategies in persons >70 years old with NSTEACS were included. Observational studies or trials involving populations outside the target range were excluded. The primary endpoint was a composite of all-cause mortality and myocardial infarction (MI) at 1 year. One-stage IPD meta-analyses were adopted by use of random-effects and fixed-effect Cox models. This meta-analysis is registered with PROSPERO (CRD42023379819). RESULTS: Six eligible studies were identified including 1479 participants. The primary endpoint occurred in 181 of 736 (24.5%) participants in the invasive management group compared with 215 of 743 (28.9%) participants in the conservative management group with a hazard ratio (HR) from random-effects model of 0.87 (95% CI 0.63-1.22; P = .43). The hazard for MI at 1 year was significantly lower in the invasive group compared with the conservative group (HR from random-effects model 0.62, 95% CI 0.44-0.87; P = .006). Similar results were seen for urgent revascularization (HR from random-effects model 0.41, 95% CI 0.18-0.95; P = .037). There was no significant difference in mortality. CONCLUSIONS: No evidence was found that routine invasive treatment for NSTEACS in older patients reduces the risk of a composite of all-cause mortality and MI within 1 year compared with conservative management. However, there is convincing evidence that invasive treatment significantly lowers the risk of repeat MI or urgent revascularisation. Further evidence is needed from ongoing larger clinical trials.
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Síndrome Coronario Agudo , Tratamiento Conservador , Intervención Coronaria Percutánea , Humanos , Tratamiento Conservador/métodos , Síndrome Coronario Agudo/terapia , Síndrome Coronario Agudo/mortalidad , Anciano , Ensayos Clínicos Controlados Aleatorios como Asunto , Revascularización Miocárdica/estadística & datos numéricos , Angiografía Coronaria , Infarto del Miocardio sin Elevación del ST/terapia , Infarto del Miocardio sin Elevación del ST/mortalidad , FemeninoRESUMEN
In acute coronary syndromes (ACS), revascularization is the standard of care. However, trials comparing contemporary coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI) are limited. Optimal revascularization in patients with multivessel coronary artery disease (MV-CAD) presenting with ACS is unclear. This is a multicentered, retrospective observational study from a large hospital system in the United States. We abstracted data in patients with MV-CAD and ACS from 2018 to 2022 who underwent revascularization with PCI, CABG, or medical management (MM). We evaluated multivariate statistics comparing categorical variables and outcomes, including all-cause mortality and myocardial infarction (MI) at 1 year. All logistic and Cox proportional-hazard models were balanced using inverse probability treatment weights accounting for age and gender. There were 295 patients with CABG (median age 66 years [interquartile range 59.7 to 73.1]; 73% male), 1,559 patients with PCI (median age 68.3 years [interquartile range 60 to 76.6]; 69.1% male], and 307 patients with MM (median age 70 years [60.9 to 77.1] 74% male]. Patients revascularized with PCI had greater all-cause mortality at 1 year (14.1% vs 5.1%; hazard ratio 2.4, confidence interval [1.5 to 3.8], p <0.001) and similar mortality to MM (13.4%). CABG also showed a reduced 1-year MI rate compared with PCI (1.7% vs 3.9%; hazard ratio 0.36, confidence interval 0.21 to 0.61, p ≤0.001), with a similar 1-year rate of MI to MM (3.9%). In conclusion, CABG is associated with lower mortality than are PCI and MM, and repeat ACS events at 1 year in patients with ACS and MV-CAD.
Asunto(s)
Síndrome Coronario Agudo , Puente de Arteria Coronaria , Enfermedad de la Arteria Coronaria , Intervención Coronaria Percutánea , Humanos , Masculino , Femenino , Anciano , Síndrome Coronario Agudo/cirugía , Síndrome Coronario Agudo/mortalidad , Persona de Mediana Edad , Estudios Retrospectivos , Intervención Coronaria Percutánea/métodos , Enfermedad de la Arteria Coronaria/cirugía , Enfermedad de la Arteria Coronaria/complicaciones , Enfermedad de la Arteria Coronaria/mortalidad , Revascularización Miocárdica/métodos , Revascularización Miocárdica/estadística & datos numéricos , Causas de Muerte/tendencias , Estados Unidos/epidemiologíaRESUMEN
BACKGROUND: In the International Study of Comparative Health Effectiveness With Medical and Invasive Approaches (ISCHEMIA) trial, among participants with stable coronary artery disease, the risk of cardiac events was similar between an invasive (INV) strategy of angiography and coronary revascularisation and a conservative (CON) strategy of initial medical therapy alone. Outcomes according to participant sex were not reported. AIMS: We aimed to analyse the outcomes of ISCHEMIA by participant sex. METHODS: We evaluated 1) the association between participant sex and the likelihood of undergoing revascularisation for participants randomised to the INV arm; 2) the risk of the ISCHEMIA primary composite outcome (cardiovascular death, any myocardial infarction [MI] or rehospitalisation for unstable angina, heart failure or resuscitated cardiac arrest) by participant sex; and 3) the contribution of the individual primary outcome components to the composite outcome by participant sex. RESULTS: Of 5,179 randomised participants, 1,168 (22.6%) were women. Female sex was independently associated with a lower likelihood of revascularisation when assigned to the INV arm (adjusted odds ratio 0.75, 95% confidence interval [CI]: 0.57-0.99; p=0.04). The INV versus CON effect on the primary composite outcome was similar between sexes (women: hazard ratio [HR] 0.96, 95% CI: 0.70-1.33; men: HR 0.90, 95% CI: 0.76-1.07; pinteraction=0.71). The contribution of the individual components to the composite outcome was similar between sexes except for procedural MI, which was significantly lower in women (9/151 [5.9%]) than men (67/519 [12.9%]; p=0.01). CONCLUSIONS: In ISCHEMIA, women assigned to the INV arm were less likely to undergo revascularisation than men. The effect of an INV versus CON strategy was consistent by sex, but women had a significantly lower contribution of procedural MI to the primary outcome.
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Enfermedad de la Arteria Coronaria , Humanos , Femenino , Masculino , Persona de Mediana Edad , Anciano , Factores Sexuales , Resultado del Tratamiento , Enfermedad de la Arteria Coronaria/terapia , Intervención Coronaria Percutánea/métodos , Angiografía Coronaria , Infarto del Miocardio , Revascularización Miocárdica/métodos , Revascularización Miocárdica/estadística & datos numéricos , Factores de RiesgoRESUMEN
BACKGROUND: Despite the significant increase in cardiovascular events in women after menopause, studies comparing postmenopausal women and men are scarce. METHODS: We analyzed data from a nationwide, multicenter, prospective registry and enrolled 2412 patients with stable chest pain who underwent elective coronary angiography. Binary coronary artery disease (b-CAD) was defined as the ≥50% stenosis of epicardial coronary arteries, including the left main coronary artery. RESULTS: Compared with the men, postmenopausal women were older (66.6â ±â 8.5 vs. 59.5â ±â 11.4 years) and had higher high-density lipoprotein cholesterol levels (49.0â ±â 12.8 vs. 43.6â ±â 11.6â mg/dl, P â <â 0.01). The prevalence of diabetes did not differ significantly ( P â =â 0.40), and smoking was more common in men than in postmenopausal women ( P â ≤â 0.01). At enrollment, b-CAD and revascularization were more common in men than in postmenopausal women (50.3% vs. 41.0% and 14.4% vs. 9.7%, respectively; both P â <â 0.01). However, multivariate analyses revealed that revascularization [odds ratio (OR): 0.72; 95% confidence interval (CI): 0.49-1.08] was not significantly related to sex and a similar result was found in age propensity-matched population (OR: 0.80; 95% CI: 0.52-1.24). During the follow-up period, the secondary composite cardiovascular outcomes were lower in postmenopausal women than in men (OR: 0.55; 95% CI: 0.31-0.98), also consistent with the result using the age propensity-mated population (OR: 0.33; 95% CI: 0.13-0.85). CONCLUSION: Postmenopausal women experienced coronary revascularization comparable to those in men at enrollment, despite the average age of postmenopausal women was 7 years older than that of men.Postmenopausal women exhibit better clinical outcomes than those of men if optimal treatment is provided.
Asunto(s)
Angiografía Coronaria , Enfermedad de la Arteria Coronaria , Posmenopausia , Sistema de Registros , Humanos , Masculino , Femenino , Persona de Mediana Edad , Angiografía Coronaria/métodos , Anciano , Factores Sexuales , Estudios Prospectivos , Enfermedad de la Arteria Coronaria/diagnóstico por imagen , Enfermedad de la Arteria Coronaria/epidemiología , Factores de Riesgo , Estenosis Coronaria/diagnóstico por imagen , Estenosis Coronaria/epidemiología , Revascularización Miocárdica/estadística & datos numéricos , Revascularización Miocárdica/métodos , Prevalencia , Angina Estable/epidemiología , Angina Estable/diagnóstico por imagen , Valor Predictivo de las Pruebas , Factores de Edad , República de Corea/epidemiologíaRESUMEN
BACKGROUND: Finding patients with chronic coronary syndromes (CCS) whom revascularization could benefit, is complicated. Myocardial flow reserve (MFR), a measurement of myocardial perfusion, has proven prognostic value on survival and risk of major adverse cardiac events (MACE). We investigated if MFR identifies who may benefit from revascularization. METHODS: Among 7462 patients from Danish hospitals examined with 82Rb PET between January 2018 and August 2020, patients with ≥5% reversible perfusion defects were followed for MACE and all-cause mortality. Associations between revascularisation (within 90 days) and outcomes according to MFR (< and ≥ 2) was assessed by Cox regression adjusted by inverse probability weighting for demographics, cardiovascular risk factors, comorbidities, and 82Rb PET variables. RESULTS: Of 1806 patients with ≥5% reversible perfusion defect, 893 (49%) had MFR < 2 and 491 underwent revascularisation (36.6% in MFR < 2 versus 17.9% MFR ≥ 2, p < 0.001). During a median follow-up of 37.0 [31.0-45.8 IQR] months, 251 experienced a MACE and 173 died. Revascularisation was associated with lower adjusted risk of all-cause mortality (hazard ratio [HR], 0.51 [95% CI, 0.30-0.88], p = 0.015) and MACE (HR, 0.54 [0.33-0.87], p = 0.012) in patients with MFR < 2 but not MFR ≥ 2 for all-cause mortality (HR 1.33 [0.52-3.40], p = 0.542) and MACE (HR 1.50 [0.79-2.84], p = 0.211). MFR significantly modified the association between revascularisation and MACE, but not all-cause mortality (interaction p-value 0.021 and 0.094, respectively). CONCLUSIONS: Revascularization was associated with improved prognosis among patients with impaired MFR. No association was seen in patients with normal MFR. In patients with regional ischemia, MFR may identify patients with a prognostic benefit from revascularization.
Asunto(s)
Reserva del Flujo Fraccional Miocárdico , Revascularización Miocárdica , Tomografía de Emisión de Positrones , Sistema de Registros , Radioisótopos de Rubidio , Humanos , Masculino , Femenino , Anciano , Revascularización Miocárdica/métodos , Revascularización Miocárdica/estadística & datos numéricos , Persona de Mediana Edad , Tomografía de Emisión de Positrones/métodos , Reserva del Flujo Fraccional Miocárdico/fisiología , Dinamarca/epidemiología , Estudios de Seguimiento , Resultado del Tratamiento , Enfermedad de la Arteria Coronaria/cirugía , Enfermedad de la Arteria Coronaria/diagnóstico por imagen , Enfermedad de la Arteria Coronaria/fisiopatología , Enfermedad de la Arteria Coronaria/mortalidadRESUMEN
Importance: Differences in the organization and financing of health systems may produce more or less equitable outcomes for advantaged vs disadvantaged populations. We compared treatments and outcomes of older high- and low-income patients across 6 countries. Objective: To determine whether treatment patterns and outcomes for patients presenting with acute myocardial infarction differ for low- vs high-income individuals across 6 countries. Design, Setting, and Participants: Serial cross-sectional cohort study of all adults aged 66 years or older hospitalized with acute myocardial infarction from 2013 through 2018 in the US, Canada, England, the Netherlands, Taiwan, and Israel using population-representative administrative data. Exposures: Being in the top and bottom quintile of income within and across countries. Main Outcomes and Measures: Thirty-day and 1-year mortality; secondary outcomes included rates of cardiac catheterization and revascularization, length of stay, and readmission rates. Results: We studied 289â¯376 patients hospitalized with ST-segment elevation myocardial infarction (STEMI) and 843â¯046 hospitalized with non-STEMI (NSTEMI). Adjusted 30-day mortality generally was 1 to 3 percentage points lower for high-income patients. For instance, 30-day mortality among patients admitted with STEMI in the Netherlands was 10.2% for those with high income vs 13.1% for those with low income (difference, -2.8 percentage points [95% CI, -4.1 to -1.5]). One-year mortality differences for STEMI were even larger than 30-day mortality, with the highest difference in Israel (16.2% vs 25.3%; difference, -9.1 percentage points [95% CI, -16.7 to -1.6]). In all countries, rates of cardiac catheterization and percutaneous coronary intervention were higher among high- vs low-income populations, with absolute differences ranging from 1 to 6 percentage points (eg, 73.6% vs 67.4%; difference, 6.1 percentage points [95% CI, 1.2 to 11.0] for percutaneous intervention in England for STEMI). Rates of coronary artery bypass graft surgery for patients with STEMI in low- vs high-income strata were similar but for NSTEMI were generally 1 to 2 percentage points higher among high-income patients (eg, 12.5% vs 11.0% in the US; difference, 1.5 percentage points [95% CI, 1.3 to 1.8 ]). Thirty-day readmission rates generally also were 1 to 3 percentage points lower and hospital length of stay generally was 0.2 to 0.5 days shorter for high-income patients. Conclusions and Relevance: High-income individuals had substantially better survival and were more likely to receive lifesaving revascularization and had shorter hospital lengths of stay and fewer readmissions across almost all countries. Our results suggest that income-based disparities were present even in countries with universal health insurance and robust social safety net systems.
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Infarto del Miocardio , Humanos , Puente de Arteria Coronaria/economía , Puente de Arteria Coronaria/estadística & datos numéricos , Estudios Transversales , Infarto del Miocardio/economía , Infarto del Miocardio/epidemiología , Infarto del Miocardio/mortalidad , Infarto del Miocardio/terapia , Infarto del Miocardio sin Elevación del ST/economía , Infarto del Miocardio sin Elevación del ST/epidemiología , Infarto del Miocardio sin Elevación del ST/mortalidad , Infarto del Miocardio sin Elevación del ST/terapia , Infarto del Miocardio con Elevación del ST/economía , Infarto del Miocardio con Elevación del ST/epidemiología , Infarto del Miocardio con Elevación del ST/mortalidad , Infarto del Miocardio con Elevación del ST/terapia , Resultado del Tratamiento , Factores Socioeconómicos , Pobreza/economía , Pobreza/estadística & datos numéricos , Anciano , Hospitalización/economía , Hospitalización/estadística & datos numéricos , Readmisión del Paciente/economía , Readmisión del Paciente/estadística & datos numéricos , Revascularización Miocárdica/economía , Revascularización Miocárdica/estadística & datos numéricos , Cateterismo Cardíaco/economía , Cateterismo Cardíaco/estadística & datos numéricos , Tiempo de Internación/economía , Tiempo de Internación/estadística & datos numéricos , InternacionalidadRESUMEN
AIM: There is no model for predicting the outcomes for coronary heart disease (CHD) patients with chronic kidney disease (CKD) after percutaneous coronary intervention (PCI). To develop and validate a model to predict major adverse cardiovascular events (MACEs) in patients with comorbid CKD and CHD undergoing PCI. METHODS: We enrolled 1714 consecutive CKD patients who underwent PCI from January 1, 2008 to December 31, 2017. In the development cohort, we used least absolute shrinkage and selection operator regression for data dimension reduction and feature selection. We used multivariable logistic regression analysis to develop the prediction model. Finally, we used an independent cohort to validate the model. The performance of the prediction model was evaluated with respect to discrimination, calibration, and clinical usefulness. RESULTS: The predictors included a positive family history of CHD, history of revascularization, ST segment changes, anemia, hyponatremia, transradial intervention, the number of diseased vessels, dose of contrast media >200 ml, and coronary collateral circulation. In the validation cohort, the model showed good discrimination (area under the receiver operating characteristic curve, 0.612; 95% confidence interval: 0.560, 0.664) and good calibration (Hosmer-Lemeshow test, P = 0.444). Decision curve analysis demonstrated that the model was clinically useful. CONCLUSIONS: We created a nomogram that predicts MACEs after PCI in CHD patients with CKD and may help improve the screening and treatment outcomes.
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Enfermedades Cardiovasculares/etiología , Enfermedad Coronaria/epidemiología , Enfermedad Coronaria/cirugía , Nomogramas , Intervención Coronaria Percutánea/efectos adversos , Insuficiencia Renal Crónica/epidemiología , Factores de Edad , Anciano , Pueblo Asiatico , Pesos y Medidas Corporales , China/epidemiología , Comorbilidad , Medios de Contraste/administración & dosificación , Electrocardiografía , Femenino , Humanos , Modelos Logísticos , Masculino , Persona de Mediana Edad , Revascularización Miocárdica/estadística & datos numéricos , Curva ROC , Estudios Retrospectivos , Medición de Riesgo , Factores de Riesgo , Factores SexualesRESUMEN
OBJECTIVE: The principal trend in acute coronary syndrome (ACS) is increasing utilization of percutaneous coronary interventions (PCI) and declining coronary artery bypass graft surgery (CABG) utilization. This study was designed to evaluate whether higher PCI:CABG ratios lead to higher in-hospital PCI or CABG mortality. METHODS: The National Readmission Database for years 2016 was queried for all hospitalized ACS patients who underwent coronary revascularization during their admission. The study population was derived from 355 US hospitals and included 103 021 patients. Hospitals were grouped based on their PCI:CABG ratio into low, intermediate, and high ratio quartiles with a median [interquartile ranges (IQR)] PCI:CABG ratio of 2.9 (2.5-3.2), 5.0 (4.3-5.9) and 8.9 (7.8-10.3), respectively multivariable logistic regression with adjustment for age, demographics and comorbidities were used to identify CABG:PCI ratio related risk for in-hospital CABG and PCI mortality. RESULTS: Higher PCI:CABG ratios correlated with an increased CABG mortality. There was a median (IQR) mortality of 2.5% (1.6-4.3) in the low ratio quartile; 3.1% (1.9-5.3) in the intermediate quartiles; and 5.3% (3.2-9.1) in the high ratio quartile (P < 0.001). On multivariate analysis, the PCI:CABG ratio was associated with an increased risk for CABG mortality with an adjusted odds ratio of 1.38 (95% CI, 1.14-1.67, P < 0.001) and 2.17 (95% CI, 1.70-2.80, P < 0.001) for hospitals with intermediate and high PCI:CABG ratios, respectively. There was no significant association between PCI:CABG ratio and PCI mortality. CONCLUSIONS: The programmatic PCI:CABG ratio is a valid indicator of optimal case selection. The PCI:CABG ratio correlates with in-hospital mortality in ACS.
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Síndrome Coronario Agudo/terapia , Puente de Arteria Coronaria/rehabilitación , Revascularización Miocárdica/estadística & datos numéricos , Intervención Coronaria Percutánea/rehabilitación , Síndrome Coronario Agudo/complicaciones , Síndrome Coronario Agudo/fisiopatología , Anciano , Puente de Arteria Coronaria/métodos , Puente de Arteria Coronaria/estadística & datos numéricos , Femenino , Mortalidad Hospitalaria/tendencias , Humanos , Masculino , Persona de Mediana Edad , Revascularización Miocárdica/métodos , Intervención Coronaria Percutánea/métodos , Intervención Coronaria Percutánea/estadística & datos numéricosRESUMEN
BACKGROUND: It remains uncertain whether intravascular ultrasound (IVUS) use and final kissing balloon (FKB) dilatation would be standard care of percutaneous coronary intervention (PCI) with a simple 1-stent technique in unprotected left main coronary artery (LMCA) stenosis. This study sought to investigate the impact of IVUS use and FKB dilatation on long-term major adverse cardiac events (MACEs) in PCI with a simple 1-stent technique for unprotected LMCA stenosis. METHODS: Between June 2006 and December 2012, 255 patients who underwent PCI with 1 drug-eluting stent for LMCA stenosis were analyzed. Mean follow-up duration was 1663 ± 946 days. Long-term MACEs were defined as death, nonfatal myocardial infarction (MI) and repeat revascularizations. RESULTS: During the follow-up, 72 (28.2%) MACEs occurred including 38 (14.9%) deaths, 21 (8.2%) nonfatal MIs and 13 (5.1%) revascularizations. The IVUS examination and FKB dilatation were done in 158 (62.0%) and 119 (46.7%), respectively. IVUS use (20.3 versus 41.2%; log-rank P < 0.001), not FKB dilatation (30.3 versus 26.5%; log-rank P = 0.614), significantly reduced MACEs. In multivariate analysis, IVUS use was a negative predictor of MACEs [hazards ratio 0.51; 95% confidence interval (CI) 0.29-0.88; P = 0.017], whereas FKB dilatation (hazard ratio 1.68; 95% CI, 1.01-2.80; P = 0.047) was a positive predictor of MACEs. In bifurcation LMCA stenosis, IVUS use (18.7 versus 48.0%; log-rank P < 0.001) significantly reduced MACEs. In nonbifurcation LMCA stenosis, FKB dilatation showed a trend of increased MACEs (P = 0.076). CONCLUSION: IVUS examination is helpful in reducing clinical events in PCI for LMCA bifurcation lesions, whereas mandatory FKB dilatation after the 1-stent technique might be harmful in nonbifurcation LMCA stenosis.