2020 Vol. 17, No. 1
Background In patients with acute ST-segment elevation myocardial infarction (STEMI) who undergo primary percutaneous coronary intervention (PCI), approximately 10% are concomitant with a chronic total occlusion (CTO) in a non-culprit vessel. However, the impact of staged CTO recanalization on prognosis in this cohort remains disputable. This study aimed to compare the long-term outcomes of staged CTO recanalization versus medical therapy in patients with STEMI after primary PCI. Methods Between January 2005 and December 2016, a total of 287 patients were treated with staged CTO-PCI (n = 91) or medical therapy (n = 196) after primary PCI in our center. The primary endpoint was major adverse cardiovascular and cerebrovascular event (MACCE), defined as a composite of all-cause death, nonfatal myocardial infarction (MI), stroke or unplanned revascularization. After propensity-score matching, 77 pairs of well-balanced patients were identified. Results The mean follow-up period was 6.06 years. Overall, the incidence of the primary endpoint of MACCE was significantly lower in staged CTO-PCI group than that in medical therapy group in both overall population (22.0% vs. 46.9%; hazard ratio (HR) = 0.48, 95% CI: 0.29?0.77) and propensity-matched cohorts (22.1% vs. 42.9%; HR: 0.48, 95% CI: 0.27?0.86). In addition, staged CTO-PCI was also associated with reduced risk of the composite of cardiac death, nonfatal MI or stroke compared with medical therapy in both overall population (9.9% vs. 26.5%; hazard ratio (HR) = 0.39, 95% CI: 0.19?0.79) and propensity-matched cohorts (9.1% vs. 22.1%; HR: 0.40, 95% CI: 0.16?0.96). After correction of the possible confounders, staged CTO-PCI was independently associated with reduced risks of MACCE (adjusted HR: 0.46, 95% CI: 0.28?0.75), the composite of cardiac death, nonfatal MI or stroke (adjusted HR: 0.45, 95% CI: 0.22?0.94) and all-cause mortality (adjusted HR: 0.32, 95% CI: 0.13?0.83). Moreover, the results of sensitivity analysis were almost concordant with the overall analysis. Conclusions In patients with STEMI and a concurrent CTO who undergo primary PCI, successful staged recanalization of CTO in the non-culprit vessels is associated with better clinical outcomes during long-term follow-up.
Objective To clarify whether cardiac cachexia (CC) alters the prognostic impact of other general risk factors in patients with heart failure (HF). Methods This was an observational study. CC was defined as the combination of a body mass index of 2 and at least one of the following biochemical abnormalities: C-reactive protein > 5 mg/L; hemoglobin n = 176, 10.9%) and a non-CC group (n = 1432, 89.1%). The primary endpoints were cardiac event and all-cause death. Results The presence of CC showed significant interactions with other risk factors including cancer, estimated glomerular filtration rate (eGFR), and sodium in predicting these endpoints. Multiple Cox proportional analysis revealed that use of a blockers [hazard ratio (HR) = 1.900, 95% confidence interval (CI): 1.045–3.455, P = 0.035) and eGFR (HR = 0.989, 95% CI: 0.980–0.998, P = 0.018) were independent predictors of cardiac event in the CC group, while age (HR = 1.020, 95% CI: 1.002–1.039, P = 0.029) and hemoglobin (HR = 0.844, 95% CI: 0.734–0.970, P = 0.017) were independent predictors of all-cause death. The survival classification and regression tree analysis showed the optimal cut-off points for cardiac event (eGFR: 59.9 mL/min per 1.73 m2) and all-cause death (age, 83 years old; hemoglobin, 10.1 g/dL) in the CC group. Conclusions In predicting prognosis, CC showed interactions with several risk factors. Renal function, age, and hemoglobin were pivotal markers in HF patients with CC.
Background Little information exists about the role of anemia in patients with acute coronary syndromes (ACS) admitted to Intensive Cardiac Care Units (ICCU). The aim of this study was to assess the prevalence of anemia and its impact on management and outcomes in this clinical setting. Methods All consecutive patients admitted to eight different ICCUs with diagnosis of non-ST segment elevation ACS (NSTEACS) were prospectively included. Anemia was defined as hemoglobin Results A total of 629 patients were included. Mean age was 66.6 years. A total of 197 patients (31.3%) had anemia. Coronary angiography was performed in most patients (96.2%). Patients with anemia were significantly older, with a higher prevalence of comorbidities, poorer left ventricle ejection fraction and higher GRACE score values. Patients with anemia underwent less often coronary angiography, but underwent more often intraaortic counterpulsation, non-invasive mechanical ventilation and renal replacement therapies. Both ICCU and hospital stay were significantly longer in patients with anemia. Both the incidence of mortality (HR = 3.36, 95% CI: 1.43–7.85, P = 0.001) and the incidence of mortality/readmission were significantly higher in patients with anemia (HR = 2.80, 95% CI: 2.03–3.86, P = 0.001). After adjusting for confounders, the association between anemia and mortality/readmission remained significant (P = 0.031). Conclusions Almost one of three NSTEACS patients admitted to ICCU had anemia. Most patients underwent coronary angiography. Anemia was independently associated to poorer outcomes at 6 months.
Background Transcatheter aortic valve replacement (TAVR) for the treatment symptomatic severe aortic stenosis (AS) is indicated in patients with intermediate or higher surgical risk. Latest trials showed TAVR, and surgical aortic valve replacement (SAVR) perform similarly at 1-year for the composite outcomes of mortality, stroke and rehospitalization. We performed a comprehensive meta-analysis to compare individual outcomes at 1-year for TAVR compared to SAVR in low-risk patients. Methods PubMed, Embase, and Cochrane central were searched for all the randomized controlled trials (RCTs) that reported 1-year comparative outcomes of TAVR and surgical aortic valve replacement (SAVR). Our conclusions are based upon the random-effects model using DerSimonian-Laird estimator. Results Data from 4 trials and 2887 randomized patients showed that TAVR had lower rates of all-cause mortality, cardiovascular mortality, and atrial fibrillation compared to SAVR at 1-year follow-up (P P Conclusions The latest randomised trial data demonstrates that in short-term, TAVR is safe and effective in reducing all-cause mortality or stroke. Longer follow-up of RCTs is needed to determine the durability of clinical benefits in TAVR over SAVR in low-risk patients.
Atrial fibrillation (AF) is a very common arrhythmia in clinical practice. Its incidence and prevalence are age-related and are growing in the last years. Age is a risk factor also for coronary artery disease (CAD) and, with the evolution of preventive care, the first event (acute coronary syndrome (ACS) or percutaneous coronary intervention (PCI)) takes place at a later age. If elderly patients with AF and CAD undergo ACS or PCI, they have indication to assume triple therapy. Triple therapy (oral anticoagulation (OAC) plus dual antiplatelet therapy (DAPT)) exposes patients to high bleeding risk. In the last 10 years, several clinical trials have tested dual therapy (OAC plus single antiplatelet therapy) in AF patients who undergo ACS or elective PCI. WOEST trial has tested warfarin + clopidogrel against triple therapy. PIONEER AF-PCI trial has tested low-dose rivaroxaban + P2Y12 inhibitor or very low-dose rivaroxaban + DAPT against standard triple therapy with warfarin. RE-DUAL PCI trial has tested two doses of dabigatran + P2Y12 inhibitor against standard triple therapy with Warfarin. AUGUSTUS trial has tested apixaban against warfarin both in dual therapy with P2Y12 inhibitor and in triple therapy with a P2Y12 inhibitor and aspirin. ENTRUST-AF PCI, last published study, has tested edoxaban + P2Y12 inhibitor against triple therapy. All these trials show dual therapy reduces significantly bleeding risk than triple therapy. In this paper, we analyze these clinical trials to understand if dual therapy results can be applied to elderly patients and what is probably the better approach in elderly AF patients undergo to ACS or PCI.