ISSN 1671-5411 CN 11-5329/R

2021 Vol. 18, No. 3

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RESEARCH ARTICLE
Hybrid coronary revascularization vs. percutaneous coronary interventions for multivessel coronary artery disease
Edward L. Hannan, Yi-Feng WU, Kimberly Cozzens, Jacqueline Tamis-Holland, Frederick S.K. Ling, Alice K. Jacobs, Ferdinand J. Venditti, Peter B. Berger, Gary Walford, Spencer B. King, III
2021, 18(3): 159-167. doi: 10.11909/j.issn.1671-5411.2021.03.003
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 OBJECTIVE Hybrid coronary revascularization (HCR) combines a minimally invasive surgical approach to the left anterior descending (LAD) artery with percutaneous coronary intervention (PCI) for non-LAD diseased coronary arteries. It is associated with shorter hospital lengths of stay and recovery times than conventional coronary artery bypass surgery, but there is little information comparing it to isolated PCI for multivessel disease. Our objective is to compare long-term outcomes of HCR and PCI for patients with multivessel disease. METHODS This cohort study used data from New York’s cardiac surgery and PCI registries in 2010−2016 to examine mortality and repeat revascularization rates for patients with multivessel coronary artery disease who underwent HCR and PCI. Cox proportional hazards methods were used to reduce selection bias. Patients were followed for a median of four years. RESULTS There was a total of 335 HCR patients (1.2%) and 25,557 PCI patients (98.8%) after exclusions. There was no difference in 6-year risk adjusted survival between HCR and PCI patients (83.17% vs. 81.65%, adjusted hazard ratio (aHR) = 0.90 (95% CI: 0.67−1.20). However, HCR patients were more likely to be free from repeat revascularization in the LAD artery (91.13% vs. 83.59%, aHR = 0.51 (95% CI: 0.34−0.77)). CONCLUSIONS For patients with multi-vessel coronary artery disease, HCR is rarely performed. There are no differences in mortality rates after four years, but HCR is associated with lower repeat revascularization rates in the LAD artery, presumably due to better longevity in left arterial mammary grafts.
Comparison of outcomes for percutaneous coronary intervention in men and women with unprotected left main disease
Sheng-Wen LIU, Chang-Dong GUAN, Feng-Huan HU, Jue CHEN, Ke-Fei DOU, Wei-Xian YANG, Yong-Jian WU, Yue-Jin YANG, Bo XU, Shu-Bin QIAO
2021, 18(3): 168-174. doi: 10.11909/j.issn.1671-5411.2021.03.004
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 BACKGROUND Percutaneous coronary intervention (PCI) in patients with unprotected left main coronary artery disease (ULMCAD) is increasing strategy in coronary artery patients. However, there is a lack of knowledge on the impact of sex on outcomes of patients undergoing ULMCAD PCI. METHODS From January 2004 to December 2015, there were 3,960 patients undergoing ULMCAD PCI at our institution, including 3,121 (78.8%) men and 839 (21.2%) women. The clinical outcome included the incidence of major adverse cardiac events (MACE) (the composite of all-cause death, myocardial infarction (MI), and revascularization), all-cause death, MI, revascularization at three years follow-up. RESULTS Compared with men, women had not significantly different MACE (14.7% vs. 14.6%, P = 0.89, all-cause death (3.5% vs. 3.7%, P = 0.76), MI (5.0% vs. 4.3%, P = 0.38), revascularization (9.1% vs. 8.9%, P = 0.86), respectively. After adjustment, rates of MACE (HR = 1.49; 95% CI: 1.24−1.81; P < 0.0001) and all-cause death (HR = 1.65; 95% CI: 1.09−2.48; P = 0.017) occurred more frequently in male patients, as well as revascularization (HR = 1.46; 95% CI: 1.16−1.85; P = 0.001). CONCLUSION In this analysis, compared to men, women undergoing ULMCAD PCI have better outcomes of MACE, all-cause death, and revascularization.
Effects of the total physical activity and its changes on incidence, progression, and remission of hypertension
Can CAI, Fang-Chao LIU, Jian-Xin LI, Ke-Yong HUANG, Xue-Li YANG, Ji-Chun CHEN, Xiao-Qing LIU, Jie CAO, Shu-Feng CHEN, Chong SHEN, Ling YU, Fang-Hong LU, Xian-Ping WU, Lian-Cheng ZHAO, Ying LI, Dong-Sheng HU, Jian-Feng HUANG, Xiao-Yang ZHOU, Xiang-Feng LU, Dong-Feng GU
2021, 18(3): 175-184. doi: 10.11909/j.issn.1671-5411.2021.03.002
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 OBJECTIVES Moderate to vigorous physical activity is recommended to prevent hypertension according to the current guidelines. However, the degree to which the total physical activity (TPA) and its changes benefit normotensives and hypertensives is uncertain. We aimed to examine the effects of TPA and its changes on the incidence, progression, and remission of hypertension in the large-scale prospective cohorts.  METHODS A total of 73,077 participants (55,101 normotensives and 17,976 hypertensives) were eligible for TPA analyses. During a mean follow-up of 7.16 years (394,038 person-years), 12,211 hypertension cases were identified. TPA was estimated as metabolic equivalents and categorized into quartiles. Cox proportional hazards regression and multivariable logistic regression were used to estimate associations of TPA and changes in TPA with incident hypertension and progression/remission of hypertension.  RESULTS Compared with the lowest quartile of TPA, normotensives at the third and the highest quartile had a decreased risk of incident hypertension, with hazard ratios (HRs) of 0.86 [95% confidence interval (CI): 0.81−0.91] and 0.81 (95% CI: 0.77−0.86), respectively. Hypertensives at the highest quartile of TPA demonstrated a decreased risk of progression of hypertension [odds ratio (OR) = 0.87, 95% CI: 0.79−0.95], and an increased probability of hypertension remission (OR = 1.17, 95% CI: 1.05−1.29). Moreover, getting active from a sedentary lifestyle during the follow-up period could reduce 25% (HR = 0.75, 95% CI: 0.58−0.96) risk of incident hypertension, whereas those becoming sedentary did not achieve benefit from initially being active.  CONCLUSIONS Our findings indicated that increasing and maintaining TPA levels could benefit normotensives, whereas higher TPA levels were needed to effectively control progression and improve remission of hypertension. Physical activity played undoubtedly an essential role in both primary and secondary prevention of hypertension.
Association of changes in waist circumference with cardiovascular disease and all-cause mortality among the elderly Chinese population: a retrospective cohort study
Xue-Ning ZHANG, Hao ZHAO, Zhan SHI, Ling YIN, Xiao-Yan ZHAO, Chun-Yu YIN, Yong-Li YANG, Song-He SHI
2021, 18(3): 185-195. doi: 10.11909/j.issn.1671-5411.2021.03.001
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 BACKGROUND To examine the association of baseline waist circumference (WC) and changes in WC with cardiovascular disease (CVD) and all-cause mortality among elderly people. METHODS A total of 30,041 eligible participants were included from a retrospective cohort in China. The same questionnaire, anthropometric and laboratory measurements were performed at baseline (2010) and the first follow-up (2013). The percent change in WC between baseline and the first follow-up was calculated to evaluate three years change of WC. We collected the occurrence of CVD and all-cause death from the first follow-up to December 31, 2018. Restricted cubic splines and Cox proportional-hazards regression models were used to evaluate the relationship between baseline WC/ changes in WC and mortality. RESULTS The dose-response relationships between baseline WC and CVD mortality were U- or J-shaped. In low WC group, compared with stable group, the fully adjusted hazard ratio (aHR) for CVD mortality was 1.60 (95% CI: 1.24−2.06) in WC gain group among men. In normal WC group, the CVD mortality risk increased with WC gain (men: aHR = 1.86, 95% CI: 1.36−2.56; women: aHR = 1.83, 95% CI: 1.29−2.58). In moderate-high WC group, the CVD mortality risk increased with WC gain (men: aHR = 1.76, 95% CI: 1.08−2.88; women: aHR = 1.46, 95% CI: 1.04−2.05) and risk decreased with WC loss (men: aHR = 0.54, 95% CI: 0.30−0.98; women: aHR = 0.59, 95% CI: 0.37−0.96). CONCLUSIONS For the elderly population, WC gain may increase CVD mortality risk regardless of baseline WC, whereas WC reduction could decrease the risk only in the moderate-high WC group.
Factors associated with change in frailty scores and long-term outcomes in older adults with coronary artery disease
S. Michael Gharacholou, Joshua P. Slusser, Ryan J. Lennon, Carolyn R. Flock, Leslie T. Cooper, Patricia A. Pellikka, Jorge Brenes Salazar, Mandeep Singh
2021, 18(3): 196-203. doi: 10.11909/j.issn.1671-5411.2021.03.006
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 OBJECTIVE Older adults with coronary artery disease (CAD) are at risk for frailty. However, little is known regarding transition in frailty measures over time or its impact on outcomes. We sought to determine the association of temporal change in frailty with long-term outcome in older adults with CAD. METHODS We re-assessed for phenotypic frailty using the Fried index (0 = not frail; 1−2 = pre-frail; ≥ 3 frail) in a cohort of CAD patients ≥ 65 years old at 2 time points 5 years apart. Factors associated with frailty worsening were assessed with scatterplots and outcomes estimated using the Kaplan-Meier method. Cox models were used to assess the risk of worsening frailty on outcome. RESULTS There were 45 subjects that completed both baseline and 5-year Fried frailty assessment. Mean age was 74.6 ± 5.9 and 30 (67%) were men. Frailty incidence increased over time: baseline (3% frail, 37% pre-frail); 5 years (10% frail, 40% pre-frail). Baseline factors were not predictors of worsening frailty score, while both slower walk time (r = 0.46; P = 0.004) and diminishing grip strength (r = −0.39; P = 0.01) were associated with worsening frailty transitions. In follow-up (median 5.2 years), long-term major adverse cardiac event (MACE) free survival (P = 0.12) or hospitalization (P = 0.98) was not different for those with worsening frailty score (referent: improved/unchanged frailty). Frailty worsening had a trend towards increased risk of MACE (HR = 1.86; 95% CI: 0.65−5.27, P = 0.25). CONCLUSIONS Frailty transitions, specifically, declines in walk time and grip strength, were strongly associated with worsening frailty score in a cohort of older adults with CAD than were baseline indices, though frailty change status was not independently associated with MACE outcomes.
Associations between low-density lipoprotein cholesterol and haemorrhagic stroke
Yun-Yan XIE, Shi-Meng LIU, Qian ZHANG, Yu JIA, Jian-Ping DING
2021, 18(3): 204-209. doi: 10.11909/j.issn.1671-5411.2021.03.011
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 OBJECTIVE To investigate the associations between the blood concentrations of low-density lipoprotein cholesterol (LDL-C) and the clinical features of haemorrhagic stroke.  METHODS This study analysed the data from patients with acute haemorrhagic stroke at a comprehensive stroke centre from 2013 to 2018. Patients were stratified into three groups according to their baseline LDL-C levels: < 70, 70 to < 100 and ≥ 100 mg/dL. We used multivariate logistic regression models to analyse the associations between LDL-C and the risks of having severe neurological deficits (National Institute Health Stroke Scale [NIHSS] scores ≥ 15) and unfavourable outcomes (modified Rankin Scale [mRS] scores>2) at discharge.  RESULTS Six-hundred and six patients were analysed. Their median age was 58 years. Among the patients, 75 (12%) patients had LDL-C levels < 70 mg/dL, 194 (32%) patients had LDL-C levels between 70 to < 100 mg/dL and the other 337 (56%) patients had LDL-C levels ≥ 100 mg/dL. Patients with higher LDL-C levels were less likely to suffer severe neurological deficits (LDL-C: 70 to < 100 vs. < 70 mg/dL, adjusted odds ratio [OR]: 0.29, 95% CI: 0.15–0.57; LDL-C: ≥ 100 vs. < 70 mg/dL, adjusted OR = 0.27, 95% CI: 0.15–0.51) and to have unfavourable outcomes at discharge (LDL-C: 70 to < 100 vs. < 70 mg/dL, adjusted OR = 0.50, 95% CI: 0.29–0.87 and LDL-C: ≥ 100 vs. < 70 mg/dL, adjusted OR = 0.46, 95% CI: 0.28–0.78).  CONCLUSIONS An LDL-C level < 70 mg/dL was independently associated with severe neurological deficits of haemorrhagic stroke and may increase the risks of unfavourable outcomes at discharge.
REVIEW
Optimal dual antiplatelet therapy strategy in elderly patients with acute coronary syndrome
Monica Verdoia, Rocco Gioscia, Giuseppe De Luca
2021, 18(3): 210-218. doi: 10.11909/j.issn.1671-5411.2021.03.010
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One out of three hospitalizations for acute coronary syndrome (ACS) involve nowadays elderly patients, carrying together a significant burden of comorbidities and a higher risk of complications. In particular, both ischemic and haemorrhagic risk are markedly enhanced in advanced age, and strictly interconnected, challenging the management of dual antiplatelet therapy (DAPT) in these patients. The recent development of several therapeutic options in terms of duration and combination of antiplatelet agents have offered a wider spectrum of opportunities for a more individualized approach in the management of DAPT after an ACS, although the criteria for the selection of the most appropriate strategy in each patient still lack validation. In particular, dose-adjustment, early aspirin discontinuation, laboratory-driven tailoring and shorter or extended DAPT have been addressed with promising safety and efficacy results. The present review provides an updated overview on the emerging evidencefrom randomized clinical trials and subanalyses dedicated to the management of DAPT in elderly patients presenting with ACS.
Heart failure in the elderly
Pablo Díez-Villanueva, César Jiménez-Méndez, Fernando Alfonso
2021, 18(3): 219-232. doi: 10.11909/j.issn.1671-5411.2021.03.009
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Heart failure (HF) is a clinical syndrome caused by structural and/or functional cardiac abnormalities, resulting in a reduced cardiac output and/or elevated intracardiac filling pressures at rest or during stress. HF is a major public health problem with high prevalence and incidence, involving both high morbidity and mortality, but also high economic costs. The incidence of HF progressively increases with age, reaching around 20% among people over 75 years old. Indeed, HF represents the leading cause of hospitalization in patients older than 65 years in Western countries. Hence, some authors even consider HF a geriatric syndrome, entailing worse prognosis and high residual disability, and often associating some complex comorbidities, common in older population, that may further complicate the course of the disease. On the other hand, however, clinical course and prognosis may be often difficult to predict. In this article, main pathophysiological issues related to the aging heart are addressed, together with key aspects related to both diagnosis and prognosis in elderly patients with HF. Besides, main geriatric conditions, common in the elderly population, are reviewed, highlighting the importance of a comprehensive and multidisciplinary approach.
LETTER TO THE EDITOR
A world's first attempt of mixed-reality system guided inferior vena cava filter implantation under remote guidance of 5G communication
Hang ZHU, Yao LI, Guang GONG, Mao-Xiang ZHAO, Lin LIU, Si-Yu YAO, Chi WANG, Xin LI, Yun-Dai CHEN
2021, 18(3): 233-237. doi: 10.11909/j.issn.1671-5411.2021.03.008
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A rare sighting: left atrial appendage thrombus seen on transthoracic echocardiogram
Jose Ruiz, Fadi Kandah, Maedeh Ganji, Robert F. Percy, Srinivasan Sattiraju
2021, 18(3): 238-239. doi: 10.11909/j.issn.1671-5411.2021.03.007
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Application of endovascular pure electrocoagulation in the management of coronary artery perforation during percutaneous coronary intervention
Qing-Yu HUANG, Bang-Wei WU, Bo JIN, Wei SHEN, Mazin Eisa, Xin-Ping LUO, Jian LI
2021, 18(3): 240-244. doi: 10.11909/j.issn.1671-5411.2021.03.005
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