RESUMEN

Early mechanical reperfusion, primarily via percutaneous coronary intervention, combined with timely antithrombotic drug administration, constitutes the main approach for managing acute coronary syndrome (ACS). Clinicians have access to a variety of antithrombotic agents, necessitating careful selection to balance reducing thrombotic events against increased bleeding risks. This review offers a comprehensive update on current antithrombotic therapy in ACS, emphasizing the need for individualized treatment strategies.

Asunto(s)

Síndrome Coronario Agudo , Fibrinolíticos , Intervención Coronaria Percutánea , Humanos , Síndrome Coronario Agudo/tratamiento farmacológico , Síndrome Coronario Agudo/cirugía , Fibrinolíticos/uso terapéutico , Intervención Coronaria Percutánea/métodos , Inhibidores de Agregación Plaquetaria/uso terapéutico , Inhibidores de Agregación Plaquetaria/administración & dosificación , Anticoagulantes/uso terapéutico , Anticoagulantes/administración & dosificación , Hemorragia/inducido químicamente , Hemorragia/prevención & control

RESUMEN

Antiplatelet therapy is integral to reduce the risk of future ischemic events following acute coronary syndrome (ACS) or percutaneous coronary intervention (PCI); this aim must be balanced by limiting the risk of bleeding. Women with ACS or undergoing PCI have distinct platelet physiology, vascular anatomy, and clinical profiles that can influence the selection of an appropriate regimen. There are procedural techniques that can enhance safety in women. The poor inclusion of women in ACS and PCI trials limits our understanding of the ideal antiplatelet regimen in women, and future studies must find ways to increase the participation of female patients.

Asunto(s)

Síndrome Coronario Agudo , Intervención Coronaria Percutánea , Inhibidores de Agregación Plaquetaria , Humanos , Síndrome Coronario Agudo/cirugía , Intervención Coronaria Percutánea/métodos , Inhibidores de Agregación Plaquetaria/uso terapéutico , Femenino , Hemorragia/inducido químicamente , Hemorragia/prevención & control

RESUMEN

BACKGROUND: It is unknown whether clinical benefit of proprotein convertase subtilisin/kexin type 9 inhibitors is associated with baseline or on-treatment triglyceride concentrations. OBJECTIVES: This study sought to examine relations between triglyceride levels and the effect of alirocumab vs placebo on cardiovascular outcomes using prespecified and post hoc analyses of the ODYSSEY OUTCOMES (Evaluation of Cardiovascular Outcomes After an Acute Coronary Syndrome During Treatment With Alirocumab) trial. METHODS: Patients with recent acute coronary syndrome (ACS) (n = 18,924) and elevated atherogenic lipoproteins despite optimized statin therapy were randomized to alirocumab 75 to 150 mg or matching placebo every 2 weeks subcutaneously. Major adverse cardiovascular events (MACE) were examined in relation to continuous or dichotomous triglyceride concentrations. RESULTS: Median baseline triglyceride concentration was 129 mg/dL. In both treatment groups, a 10-mg/dL higher baseline concentration was associated with an adjusted MACE HR of 1.008 (95% CI: 1.003-1.013; P < 0.005). Baseline triglycerides ≥150 vs <150 mg/dL were associated with a HR of 1.184 (95% CI: 1.080-1.297; P < 0.005). Versus placebo, alirocumab reduced low-density lipoprotein cholesterol from baseline (average, 54.7%) and reduced MACE (HR: 0.85; 95% CI: 0.78-0.93). At month 4, triglyceride levels were reduced from baseline by median 17.7 mg/dL (P < 0.001) and 0.9 mg/dL (P = NS) with alirocumab and placebo, respectively. A 10-mg/dL decline from baseline in triglycerides was associated with lower subsequent risk of MACE with placebo (HR: 0.988; 95% CI: 0.982-0.995; P < 0.005) but not with alirocumab (HR: 0.999; 95% CI: 0.987-1.010; P = 0.82). CONCLUSIONS: Among patients with recent ACS on optimized statin therapy, baseline triglycerides was associated with cardiovascular risk. However, the reduction in triglycerides with alirocumab did not contribute to its clinical benefit. (ODYSSEY Outcomes: Evaluation of Cardiovascular Outcomes After an Acute Coronary Syndrome During Treatment With Alirocumab; NCT01663402).

Asunto(s)

Síndrome Coronario Agudo , Anticuerpos Monoclonales Humanizados , Triglicéridos , Humanos , Síndrome Coronario Agudo/tratamiento farmacológico , Síndrome Coronario Agudo/sangre , Anticuerpos Monoclonales Humanizados/uso terapéutico , Masculino , Femenino , Triglicéridos/sangre , Persona de Mediana Edad , Anciano , Método Doble Ciego , Resultado del Tratamiento , Inhibidores de PCSK9/uso terapéutico , Enfermedades Cardiovasculares/sangre , Enfermedades Cardiovasculares/epidemiología , Enfermedades Cardiovasculares/prevención & control

RESUMEN

INTRODUCTION: Risk prediction models, such as The Society of Thoracic Surgeons (STS) risk score and the European System for Cardiac Operative Risk Evaluation II (EuroSCORE II), are recommended for assessing operative mortality in coronary artery bypass grafting (CABG). However, their performance is questionable in Brazil. OBJECTIVE: To assess the performance of the STS score and EuroSCORE II in isolated CABG at a Brazilian reference center. METHODS: Observationaland prospective study including 438 patients undergoing isolated CABG from May 2022-May 2023 at the Instituto Dante Pazzanese de Cardiologia. Observed mortality was compared with predicted mortality (STS score and EuroSCORE II) by discrimination (area under the curve [AUC]) and calibration (observed/expected ratio [O/E]) in the total sample and subgroups of stable coronary artery disease (CAD) and acute coronary syndrome (ACS). RESULTS: Observed mortality was 4.3% (n=19) and estimated at 1.21% and 2.74% by STS and EuroSCORE II, respectively. STS (AUC=0.646; 95% confidence interva [CI] 0.760-0.532) and EuroSCORE II (AUC=0.697; 95% CI 0.802-0.593) presented poor discrimination. Calibration was absent for the North American mode (P<0.05) and reasonable for the European model (O/E=1.59, P=0.056). In the subgroups, EuroSCORE II had AUC of 0.616 (95% CI 0.752-0.480) and 0.826 (95% CI 0.991-0.661), while STS had AUC of 0.467 (95% CI 0.622-0.312) and 0.855 (95% CI 1.0-0.706) in ACS and CAD patients, respectively, demonstrating good score performance in stable patients. CONCLUSION: The predictive models did not perform optimally in the total sample, but the EuroSCORE was superior, especially in elective stable patients, where accuracy was satisfactory.

Asunto(s)

Puente de Arteria Coronaria , Enfermedad de la Arteria Coronaria , Humanos , Puente de Arteria Coronaria/mortalidad , Femenino , Masculino , Estudios Prospectivos , Brasil , Anciano , Persona de Mediana Edad , Medición de Riesgo/métodos , Enfermedad de la Arteria Coronaria/cirugía , Enfermedad de la Arteria Coronaria/mortalidad , Factores de Riesgo , Síndrome Coronario Agudo/cirugía , Síndrome Coronario Agudo/mortalidad , Mortalidad Hospitalaria , Reproducibilidad de los Resultados

RESUMEN

BACKGROUNDS AND OBJECTIVE: Statins, inhibitors of 3-hydroxy-3-methylglutaryl coenzyme A reductase, are pivotal in managing hypercholesterolemia and reducing cardiovascular risk. While rosuvastatin demonstrates superior efficacy and tolerability compared to other statins, its safety profile in elderly patients older than 75 years old with acute coronary syndrome (ACS) remains underexplored. So, the objective of this study is to evaluate the frequency of adverse reactions and investigate the efficacy of high-dose rosuvastatin on lipid profiles in elderly patients aged over 75 with ACS. METHODS: In this observational study, 110 consecutive elderly ACS patients attending Modarres Hospital in Tehran, Iran, in 2019 were enrolled. The effects of high-dose rosuvastatin were assessed in elderly patients older than 75 years old by comparison of the adverse effects, lipid profile, cardiac function, and other biomarkers at the baseline and after 6 weeks of rosuvastatin therapy with a dose of 40 mg. RESULTS: Following 6 weeks of treatment, there was a significant reduction in total cholesterol (136.2 ± 24.3 to 115.5 ± 24.0, p = 0.001) and LDL levels (72.6 ± 17.5 to 50.9 ± 18.9, p = 0.001), accompanied by a notable increase in HDL levels (38.3 ± 7.1 to 47.2 ± 7.4, p = 0.001). Cardiac function, as measured by ejection fraction (EF), significantly improved from 43.4 ± 8.8 to 48.5 ± 8.5 (p = 0.001). Adverse effects such as cramps (N = 12, p = 0.001), weakness (N = 28, p = 0.001), and anorexia (N = 12, p = 0.001) were reported but did not warrant discontinuation of therapy. Notably, no cases of jaundice were observed. Two deaths occurred due to major adverse cardiac events (MACE) during the study period, unrelated to stroke or recurrent myocardial infarction. CONCLUSION: Totally, high-dose rosuvastatin therapy effectively improved lipid profiles, cardiac function, and liver enzyme levels in elderly ACS patients, with manageable adverse effects. These findings underscore the importance of rosuvastatin in optimizing cardiovascular health in this vulnerable population.

Asunto(s)

Síndrome Coronario Agudo , Biomarcadores , Inhibidores de Hidroximetilglutaril-CoA Reductasas , Rosuvastatina Cálcica , Humanos , Rosuvastatina Cálcica/efectos adversos , Rosuvastatina Cálcica/administración & dosificación , Rosuvastatina Cálcica/uso terapéutico , Síndrome Coronario Agudo/tratamiento farmacológico , Síndrome Coronario Agudo/sangre , Síndrome Coronario Agudo/diagnóstico , Anciano , Masculino , Femenino , Inhibidores de Hidroximetilglutaril-CoA Reductasas/efectos adversos , Inhibidores de Hidroximetilglutaril-CoA Reductasas/administración & dosificación , Inhibidores de Hidroximetilglutaril-CoA Reductasas/uso terapéutico , Resultado del Tratamiento , Anciano de 80 o más Años , Irán , Biomarcadores/sangre , Factores de Tiempo , Factores de Edad , Dislipidemias/tratamiento farmacológico , Dislipidemias/diagnóstico , Dislipidemias/sangre , Lípidos/sangre , Estudios Prospectivos

RESUMEN

The CYP2C19 enzyme metabolizes clopidogrel, a prodrug, to its active form. Approximately 30% of individuals inherit a loss-of-function (LoF) polymorphism in the CYP2C19 gene, leading to reduced formation of the active clopidogrel metabolite. Reduced clopidogrel effectiveness has been well documented in patients with an LoF allele following an acute coronary syndrome or percutaneous coronary intervention. Prasugrel or ticagrelor is recommended in those with an LoF allele as neither is affected by CYP2C19 genotype. Although data demonstrate improved outcomes with a CYP2C19-guided approach to P2Y12 inhibitor selection, genotyping has not yet been widely adopted in clinical practice.

Asunto(s)

Citocromo P-450 CYP2C19 , Antagonistas del Receptor Purinérgico P2Y , Humanos , Antagonistas del Receptor Purinérgico P2Y/uso terapéutico , Citocromo P-450 CYP2C19/genética , Síndrome Coronario Agudo/tratamiento farmacológico , Síndrome Coronario Agudo/genética , Clopidogrel/uso terapéutico , Intervención Coronaria Percutánea/métodos , Genotipo , Ticagrelor/uso terapéutico , Inhibidores de Agregación Plaquetaria/uso terapéutico , Clorhidrato de Prasugrel/uso terapéutico , Polimorfismo Genético

RESUMEN

BACKGROUND: Dual antiplatelet therapy (DAPT) for 12 months is the standard of care after coronary stenting in patients with acute coronary syndrome (ACS). The aim of this individual patient-level meta-analysis was to summarise the evidence comparing DAPT de-escalation to ticagrelor monotherapy versus continuing DAPT for 12 months after coronary drug-eluting stent implantation. METHODS: A systematic review and individual patient data (IPD)-level meta-analysis of randomised trials with centrally adjudicated endpoints was performed to evaluate the comparative efficacy and safety of ticagrelor monotherapy (90 mg twice a day) after short-term DAPT (from 2 weeks to 3 months) versus 12-month DAPT in patients undergoing percutaneous coronary intervention with a coronary drug-eluting stent. Randomised trials comparing P2Y12 inhibitor monotherapy with DAPT after coronary revascularisation were searched in Ovid MEDLINE, Embase, and two websites (www.tctmd.com and www.escardio.org) from database inception up to May 20, 2024. Trials that included patients with an indication for long-term oral anticoagulants were excluded. The risk of bias was assessed using the revised Cochrane risk-of-bias tool. The principal investigators of the eligible trials provided IPD by means of an anonymised electronic dataset. The three ranked coprimary endpoints were major adverse cardiovascular or cerebrovascular events (MACCE; a composite of all-cause death, myocardial infarction, or stroke) tested for non-inferiority in the per-protocol population; and Bleeding Academic Research Consortium (BARC) 3 or 5 bleeding and all-cause death tested for superiority in the intention-to-treat population. All outcomes are reported as Kaplan-Meier estimates. The non-inferiority was tested using a one-sided α of 0·025 with the prespecified non-inferiority margin of 1·15 (hazard ratio [HR] scale), followed by the ranked superiority testing at a two-sided α of 0·05. This study is registered with PROSPERO (CRD42024506083). FINDINGS: A total of 8361 unique citations were screened, of which 610 records were considered potentially eligible during the screening of titles and abstracts. Of these, six trials that randomly assigned patients to ticagrelor monotherapy or DAPT were identified. De-escalation took place a median of 78 days (IQR 31-92) after intervention, with a median duration of treatment of 334 days (329-365). Among 23 256 patients in the per-protocol population, MACCE occurred in 297 (Kaplan-Meier estimate 2·8%) with ticagrelor monotherapy and 332 (Kaplan-Meier estimate 3·2%) with DAPT (HR 0·91 [95% CI 0·78-1·07]; p=0·0039 for non-inferiority; τ2<0·0001). Among 24 407 patients in the intention-to-treat population, the risks of BARC 3 or 5 bleeding (Kaplan-Meier estimate 0·9% vs 2·1%; HR 0·43 [95% CI 0·34-0·54]; p<0·0001 for superiority; τ2=0·079) and all-cause death (Kaplan-Meier estimate 0·9% vs 1·2%; 0·76 [0·59-0·98]; p=0·034 for superiority; τ2<0·0001) were lower with ticagrelor monotherapy. Trial sequential analysis showed strong evidence of non-inferiority for MACCE and superiority for bleeding among the overall and ACS populations (the z-curve crossed the monitoring boundaries or the required information size without crossing the futility boundaries or approaching the null). The treatment effects were heterogeneous by sex for MACCE (p interaction=0·041) and all-cause death (p interaction=0·050), indicating a possible benefit in women with ticagrelor monotherapy, and by clinical presentation for bleeding (p interaction=0·022), indicating a benefit in ACS with ticagrelor monotherapy. INTERPRETATION: Our study found robust evidence that, compared with 12 months of DAPT, de-escalation to ticagrelor monotherapy does not increase ischaemic risk and reduces the risk of major bleeding, especially in patients with ACS. Ticagrelor monotherapy might also be associated with a mortality benefit, particularly among women, which warrants further investigation. FUNDING: Cardiocentro Ticino Institute, Ente Ospedaliero Cantonale.

Asunto(s)

Síndrome Coronario Agudo , Terapia Antiplaquetaria Doble , Intervención Coronaria Percutánea , Inhibidores de Agregación Plaquetaria , Ensayos Clínicos Controlados Aleatorios como Asunto , Ticagrelor , Humanos , Ticagrelor/uso terapéutico , Ticagrelor/administración & dosificación , Síndrome Coronario Agudo/tratamiento farmacológico , Inhibidores de Agregación Plaquetaria/uso terapéutico , Inhibidores de Agregación Plaquetaria/administración & dosificación , Terapia Antiplaquetaria Doble/métodos , Hemorragia/inducido químicamente , Stents Liberadores de Fármacos , Resultado del Tratamiento

Asunto(s)

Síndrome Coronario Agudo , Inhibidores de Agregación Plaquetaria , Ticagrelor , Ticagrelor/uso terapéutico , Humanos , Síndrome Coronario Agudo/tratamiento farmacológico , Inhibidores de Agregación Plaquetaria/uso terapéutico , Antagonistas del Receptor Purinérgico P2Y/uso terapéutico , Ensayos Clínicos Controlados Aleatorios como Asunto , Resultado del Tratamiento

RESUMEN

BACKGROUND: The clinical benefits of optical frequency domain imaging (OFDI)-guided percutaneous coronary intervention (PCI) for acute coronary syndrome (ACS) remain unclear. AIMS: We sought to compare intravascular ultrasound (IVUS)- and OFDI-guided PCI in patients with ACS. METHODS: OPINION ACS is a multicentre, prospective, randomised, non-inferiority trial that compared OFDI-guided PCI with IVUS-guided PCI using current-generation drug-eluting stents in ACS patients (n=158). The primary endpoint was in-stent minimum lumen area (MLA), assessed using 8-month follow-up OFDI. RESULTS: Patients presented with ST-segment elevation myocardial infarction (55%), non-ST-segment elevation myocardial infarction (29%), or unstable angina pectoris (16%). PCI procedural success was achieved in all patients, with comparably low periprocedural complications rates in both groups. Immediately after PCI, the minimum stent area (p=0.096) tended to be smaller for OFDI versus IVUS guidance. Proximal stent edge dissection (p=0.012) and irregular protrusion (p=0.03) were significantly less frequent in OFDI-guided procedures than in IVUS-guided procedures. Post-PCI coronary flow, assessed using corrected Thrombolysis in Myocardial Infarction frame counts, was significantly better in the OFDI-guided group than in the IVUS-guided group (p<0.001). The least squares mean (95% confidence interval [CI]) in-stent MLA at 8 months was 4.91 (95% CI: 4.53-5.30) mm2 and 4.76 (95% CI: 4.35-5.17) mm2 in the OFDI- and IVUS-guided groups, respectively, demonstrating the non-inferiority of OFDI guidance (pnon-inferiority<0.001). The average neointima area tended to be smaller in the OFDI-guided group. The frequency of major adverse cardiac events was similar. CONCLUSIONS: Among ACS patients, OFDI-guided PCI and IVUS-guided PCI were equally safe and feasible, with comparable in-stent MLA at 8 months. OFDI guidance may be a potential option in ACS patients. This study was registered in the Japan Registry of Clinical Trials (jrct.niph.go.jp: jRCTs052190093).

Asunto(s)

Síndrome Coronario Agudo , Stents Liberadores de Fármacos , Intervención Coronaria Percutánea , Ultrasonografía Intervencional , Humanos , Ultrasonografía Intervencional/métodos , Intervención Coronaria Percutánea/métodos , Masculino , Síndrome Coronario Agudo/terapia , Síndrome Coronario Agudo/diagnóstico por imagen , Síndrome Coronario Agudo/cirugía , Femenino , Persona de Mediana Edad , Anciano , Resultado del Tratamiento , Estudios Prospectivos , Tomografía de Coherencia Óptica/métodos , Infarto del Miocardio con Elevación del ST/diagnóstico por imagen , Infarto del Miocardio con Elevación del ST/terapia , Infarto del Miocardio con Elevación del ST/cirugía , Angina Inestable/terapia , Angina Inestable/diagnóstico por imagen , Angina Inestable/cirugía

RESUMEN

OBJECTIVE: Coronary artery disease is one of the most common causes of disability and work loss among working-age individuals. Since the ability to return to work after cardiovascular events depends on several factors, identifying these factors can be helpful in treatment planning and effective rehabilitation. In this study, we aimed to assess the employment status and related factors one year after angiography in patients with stable angina and acute coronary syndrome and to investigate the impact of occupational factors on angiographic characteristics. METHODS: This retrospective study included 447 patients with coronary artery disease who underwent angiography between February 2020 and March 2021 at a teaching hospital. Data regarding employment status and other related variables, including the Job Content Questionnaire, were collected through medical record reviews and telephone interviews one year after hospital discharge. The participants' occupational factors and return-to-work status were then compared. RESULTS: One year after angiography, the rate of returning to work was 70%. Of these, 86.3% had resumed their previous job. Factors associated with a reduced return to work included major coronary artery involvement, a history of hypertension, lower ejection fraction, and increased hospitalization days. Occupational risk factors such as low income, longer working hours, and high job demand also decreased the likelihood of returning to employment. CONCLUSION: Various clinical and socioeconomic factors can predict the probability of returning to work after angiography in patients with coronary artery disease. Considering these factors could be useful in formulating clinical guidelines to improve employment outcomes for these patients.

Asunto(s)

Angiografía Coronaria , Reinserción al Trabajo , Humanos , Reinserción al Trabajo/estadística & datos numéricos , Masculino , Femenino , Persona de Mediana Edad , Estudios Retrospectivos , Angiografía Coronaria/estadística & datos numéricos , Factores de Riesgo , Enfermedad de la Arteria Coronaria/diagnóstico por imagen , Síndrome Coronario Agudo/diagnóstico por imagen , Síndrome Coronario Agudo/rehabilitación , Anciano , Adulto , Empleo/estadística & datos numéricos , Angina Estable/diagnóstico por imagen

RESUMEN

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.

Asunto(s)

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/métodos

RESUMEN

ABSTRACT: Guidelines on antiplatelet recommendation for CYP2C19 intermediate metabolizer (IM) have not come to an agreement. This study aimed to evaluate the clinical benefit of ticagrelor when compared with high-dose clopidogrel in CYP2C19 IM after percutaneous coronary intervention for acute coronary syndromes. Patients were enrolled according to CYP2C19 genotype and individual antiplatelet therapy. Patient characteristics and clinical outcomes were collected through electronic medical record system. The primary outcome was major adverse cardiac and cerebrovascular event (MACCE), namely a composite of death from cardiovascular causes, myocardial infarction, stroke, and stent thrombosis within 12 months. The secondary outcome was Bleeding Academic Research Consortium scale bleeding events within 12 months. The Cox proportional hazards regression model was performed, with inverse probability treatment weighting (IPTW) adjusting for potential confounders. A total of 532 CYP2C19 IM were enrolled in this retrospective single-center study. No statistically significant difference in incidence rate of MACCE was found between patients receiving ticagrelor versus clopidogrel (7.01 vs. 9.52 per 100 patient-years; IPTW-adjusted hazard ratio 0.71; 95% confidence interval: 0.32-1.58; adjusted log-rank P = 0.396), but the incidence rate of Bleeding Academic Research Consortium type 2, 3, or 5 bleeding events was statistically higher in the loss of function-ticagrelor group than in the loss of function-clopidogrel group (13.53 vs. 6.16 per 100 patient-years; IPTW-adjusted hazard ratio: 2.29; 95% confidence interval: 1.10-4.78; adjusted log-rank P = 0.027). Ticagrelor treatment in CYP2C19 IM resulted in a statistically higher risk of bleeding compared with high-dose clopidogrel, whereas a clear association between treatments and MACCE warrants further investigations.

Asunto(s)

Síndrome Coronario Agudo , Clopidogrel , Citocromo P-450 CYP2C19 , Hemorragia , Intervención Coronaria Percutánea , Variantes Farmacogenómicas , Inhibidores de Agregación Plaquetaria , Ticagrelor , Humanos , Citocromo P-450 CYP2C19/genética , Citocromo P-450 CYP2C19/metabolismo , Ticagrelor/efectos adversos , Ticagrelor/administración & dosificación , Clopidogrel/efectos adversos , Clopidogrel/administración & dosificación , Síndrome Coronario Agudo/terapia , Síndrome Coronario Agudo/mortalidad , Síndrome Coronario Agudo/diagnóstico , Masculino , Intervención Coronaria Percutánea/efectos adversos , Intervención Coronaria Percutánea/mortalidad , Femenino , Inhibidores de Agregación Plaquetaria/efectos adversos , Inhibidores de Agregación Plaquetaria/administración & dosificación , Persona de Mediana Edad , Anciano , Estudios Retrospectivos , Resultado del Tratamiento , Hemorragia/inducido químicamente , Factores de Riesgo , Factores de Tiempo , Medición de Riesgo , Fenotipo

Asunto(s)

Síndrome Coronario Agudo , Intervención Coronaria Percutánea , Humanos , Síndrome Coronario Agudo/terapia , Síndrome Coronario Agudo/cirugía , Intervención Coronaria Percutánea/efectos adversos , Intervención Coronaria Percutánea/métodos , Resultado del Tratamiento , Estenosis Coronaria/terapia , Estenosis Coronaria/diagnóstico por imagen , Estenosis Coronaria/cirugía , Angiografía Coronaria

Asunto(s)

Síndrome Coronario Agudo , Fibrilación Atrial , Humanos , Fibrilación Atrial/terapia , Fibrilación Atrial/fisiopatología , Fibrilación Atrial/diagnóstico , Fibrilación Atrial/complicaciones , Síndrome Coronario Agudo/terapia , Intervención Coronaria Percutánea , Factores de Riesgo , Resultado del Tratamiento

Asunto(s)

Síndrome Coronario Agudo , Hemorragia , Intervención Coronaria Percutánea , Inhibidores de Agregación Plaquetaria , Humanos , Intervención Coronaria Percutánea/efectos adversos , Síndrome Coronario Agudo/terapia , Hemorragia/inducido químicamente , Inhibidores de Agregación Plaquetaria/efectos adversos , Inhibidores de Agregación Plaquetaria/uso terapéutico , Inhibidores de Agregación Plaquetaria/administración & dosificación , Terapia Antiplaquetaria Doble/efectos adversos , Terapia Antiplaquetaria Doble/métodos , Factores de Riesgo , Resultado del Tratamiento , Factores de Tiempo

RESUMEN

BACKGROUND: The effect of proprotein convertase subtilisin kexin type (PCSK9) inhibitors on blood lipids and major adverse cardiovascular events (MACEs) is still controversial for acute coronary syndrome (ACS) patients. This study aimed to evaluate the efficacy and safety of PCSK9 inhibitors for ACS patients. METHODS: We searched the following databases until March 2023: PubMed, Embase, Cochrane, Web of Science, CNKI, Chongqing VIP Database and Wan Fang Database. Finally, all randomized controlled trials, retrospective studies and prospective studies were included in the analysis. RESULTS: A total of 20 studies involving 48,621 patients were included in this meta-analysis. The results demonstrated that PCSK9 inhibitors group was more beneficial for ACS patients compared to control group (receiving statins alone or placebo). The meta-analysis showed: there was no significant difference in high density lipoprotein cholesterol between PCSK9 inhibitors group and control group (standard mean difference = 0.17, 95% confidence interval [CI]: -0.02 to 0.36, P = .08), while the level of low density lipoprotein cholesterol in PCSK9 inhibitors group was lower than that in control group (standard mean difference = -2.32, 95% CI: -2.81 to -1.83, P < .00001). Compared with the control group, the PCSK9 inhibitors group also decreased the levels of total cholesterol and triglycerides (mean difference = -1.24, 95% CI: -1.40 to -1.09, P < .00001, mean difference = -0.36, 95% CI: -0.56 to -0.16, P = .0004). Moreover, compared with the control group, PCSK9 inhibitors group could reduce the incidence of MACEs (relative risk [RR] = 0.87, 95% CI: 0.83-0.91; P < .00001). However, this study showed that the incidence of drug-induced adverse events in PCSK9 inhibitors group was higher than that in the control group (RR = 1.15, 95% CI: 1.05-1.25, P < .0001). CONCLUSION: Although this study demonstrates that PCSK9 inhibitors have higher drug-induced adverse events, they can not only reduce low-density lipoprotein cholesterol levels but also reduce the incidence of MACEs simultaneously. However, these findings needed to be further verified through large sample, multicenter, double-blind randomized controlled trials.

Asunto(s)

Síndrome Coronario Agudo , Inhibidores de PCSK9 , Humanos , Síndrome Coronario Agudo/tratamiento farmacológico , Síndrome Coronario Agudo/sangre , LDL-Colesterol/sangre , LDL-Colesterol/efectos de los fármacos , Anticolesterolemiantes/uso terapéutico , Anticolesterolemiantes/efectos adversos , Inhibidores de Hidroximetilglutaril-CoA Reductasas/uso terapéutico , Inhibidores de Hidroximetilglutaril-CoA Reductasas/efectos adversos , Proproteína Convertasa 9

RESUMEN

SOURCE CITATION: Kelham M, Vyas R, Ramaseshan R, et al. Non-ST-elevation acute coronary syndromes with previous coronary artery bypass grafting: a meta-analysis of invasive vs. conservative management. Eur Heart J. 2024;45:2380-2391. 38805681.

Asunto(s)

Síndrome Coronario Agudo , Tratamiento Conservador , Puente de Arteria Coronaria , Humanos , Síndrome Coronario Agudo/terapia , Infarto del Miocardio sin Elevación del ST/terapia , Resultado del Tratamiento , Intervención Coronaria Percutánea

RESUMEN

SOURCE CITATION: Alshahrani NS, Hartley A, Howard J, et al. Randomized trial of remote assessment of patients after an acute coronary syndrome. J Am Coll Cardiol. 2024;83:2250-2259. 38588928.

Asunto(s)

Síndrome Coronario Agudo , Readmisión del Paciente , Telemedicina , Humanos , Síndrome Coronario Agudo/terapia , Readmisión del Paciente/estadística & datos numéricos , Masculino , Femenino , Persona de Mediana Edad

RESUMEN

BACKGROUND: In patients with acute coronary syndrome (ACS) and multivessel disease (MVD), complete revascularization (CR) improves prognosis. This meta-analysis, summarizing recent RCTs, contrasts short-term and long-term clinical outcomes between immediate complete revascularization (ICR) and staged complete revascularization (SCR). METHODS: We systematically searched the online database and eight RCTs were involved. The primary outcomes included long-term unplanned ischemia-driven revascularization, re-infarction, combined cardiovascular (CV) death or myocardial infarction (MI), all-cause death, CV death, stroke, and hospitalization for heart failure (HHF). The secondary outcomes were 1-month unplanned ischemia-driven revascularization, re-infarction, all-cause death, and CV death. Safety endpoints included stent thrombosis and major bleeding. RESULTS: Eight RCTs comprising 5198 patients were involved. ICR reduced long-term unplanned ischemia-driven revascularization (RR 0.64, 95% CI 0.51-0.81, p < 0.001), combined CV death or MI (HR 0.51, 95% CI 0.34-0.78, p = 0.002), and re-infarction (RR 0.66,95% CI 0.48 to 0.91, p = 0.012) compared with SCR. ICR also decreased 1-month unplanned ischemia-driven revascularization (RR 0.41, 95% CI: 0.21-0.77, p = 0.006) and re-infarction (RR 0.33, 95% CI:0.15-0.74, p = 0.007) but increased 1-month all-cause death (RR 2.22, 95% CI 1.06-4.65, p = 0.034). CONCLUSION: In ACS patients with MVD, we first found that ICR significantly lowered the risk of both short-term and long-term unplanned ischemia-driven revascularization and re-infarction, as well as the long-term composite outcome of CV death or MI compared with SCR. However, there may be an increase in 1-month all-cause death in the ICR group.

Asunto(s)

Síndrome Coronario Agudo , Humanos , Síndrome Coronario Agudo/cirugía , Síndrome Coronario Agudo/mortalidad , Síndrome Coronario Agudo/terapia , Revascularización Miocárdica/métodos , Intervención Coronaria Percutánea/métodos , Factores de Riesgo , Factores de Tiempo , Resultado del Tratamiento

RESUMEN

Background: Recent studies have shown that the triglyceride glucose index (TyG) and cystatin C (CysC) are closely related to cardiovascular disease, but there is limited research on the prognosis of patients with acute coronary syndrome (ACS) after percutaneous coronary intervention (PCI). The aim of this study was to explore the predictive value of the combination of the TyG index and CysC in predicting major adverse cardiovascular events (MACEs) in ACS patients who underwent PCI. Methods: This retrospective study included 319 ACS patients who underwent PCI. The clinical endpoint was the occurrence of MACEs, including all-cause mortality, heart failure, non-fatal myocardial infarction, target vessel revascularization, and angina requiring hospitalization. Patients were classified into MACEs (65 cases) and non-MACEs (254 cases) groups. Univariate factor and multivariate analysis were used to identify predictors of MACEs. The receiver operating curve (ROC) of the prediction model of MACEs was determined. Additionally, the net reclassification improvement and integrated discrimination improvement indexes were calculated to further assess the additional predictive value of the risk factors for MACEs. Subgroup and interaction analysis between the TyG index combined with CysC and MACEs were conducted in various subgroups. Patients were stratified according to the optimal cutoff point value of the TyG index and the CysC determined by ROC curve analysis. The Kaplan-Meier analysis method was used to construct a survival curve 1 year after PCI. Results: During a median follow-up period of 14 months, 65 (20.38%) patients had experienced at least one primary endpoint event. Multivariate logistic regression analysis indicated that the TyG index and CysC were independently associated with an increased risk of MACEs after PCI (OR, 2.513, 95% CI 1.451-4.351, P= 0.001; and OR, 4.741, 95% CI 1.344-16.731, P=0.016, respectively). The addition of the TyG index and CysC to the baseline risk model had the strongest incremental effect for predicting MACEs in terms of the C-statistic from 0.789 (95% CI 0.723-0.855, P<0.001) to 0.799 (95% CI 0.733-0.865, P<0.001). Furthermore, Kaplan-Meier analysis demonstrated that a TyG index greater than 9.325 and a CysC value greater than 1.065 mg/ml were significantly associated with an increased risk of MACEs (log-rank, all P < 0.01). Conclusion: The TyG index predicts MACEs after PCI in patients with ASC independent of known cardiovascular risk factors. Adjustment of the CysC by the TyG index further improves the predictive ability for MACEs in patients with ACS undergoing PCI. Thus, both of them are expected to become new prognostic indicators for MACEs in patients with ACS after PCI.

Asunto(s)

Síndrome Coronario Agudo , Glucemia , Cistatina C , Intervención Coronaria Percutánea , Valor Predictivo de las Pruebas , Triglicéridos , Humanos , Síndrome Coronario Agudo/sangre , Síndrome Coronario Agudo/diagnóstico , Síndrome Coronario Agudo/mortalidad , Femenino , Masculino , Cistatina C/sangre , Estudios Retrospectivos , Pronóstico , Persona de Mediana Edad , Triglicéridos/sangre , Anciano , Glucemia/análisis , Glucemia/metabolismo , Biomarcadores/sangre , Factores de Riesgo