Background
Measurement of post‐percutaneous coronary intervention (PCI) fractional flow reserve (FFR) demonstrates residual ischemia in a large percentage of cases deemed angiographically successful ...which, in turn, has been associated with worse long‐term outcomes. It has recently been shown that a resting pressure index, Pd/Pa, has prognostic value post stenting, however, its diagnostic value relative to FFR post‐PCI has not been evaluated.
Methods
The diagnostic accuracy of Pd/Pa in identifying ischemia (FFR≤0.80) pre‐ and post‐PCI was evaluated. Three patient subsets were analyzed. A reference pre‐PCI cohort of 1,255 patients (1,560 vessels) was used to measure the accuracy of pre‐PCI Pd/Pa vs. FFR. A derivation post‐PCI group of 574 patient (664 vessels) was then used to calculate the diagnostic accuracy of post‐PCI Pd/Pa vs. FFR. A final prospective validation cohort of 230 patients (255 vessels) was used to test and validate the diagnostic performance of post‐PCI Pd/Pa.
Results
Median Pd/Pa and FFR were 0.90 (IQR 0.90–0.98) and 0.80 (IQR 0.71–0.88) in the reference pre‐PCI model, 0.96 (IQR 0.93–1.00) and 0.87 (IQR 0.77–0.90) in the post‐PCI derivation model, and 0.94 (IQR 0.89–0.97) and 0.84 (IQR 0.77–0.90) in the post‐PCI validation model respectively. There was a strong linear correlation between Pd/Pa and FFR in all three models (p < 0.0001). Using ROC analysis, the optimal Pd/Pa cutoff value to predict a FFR ≤ 0.80 was ≤0.92 (AUC 0.87) in the pre‐PCI model, ≤0.93 (AUC 0.85) in the post‐PCI derivation model, and ≤ 0.90 (AUC 0.91) in the post‐PCI validation model. Using a hybrid strategy of post‐PCI Pd/Pa and post‐PCI FFR when necessary (25% patients), overall diagnostic accuracy was improved to 95%.
Conclusions
Pd/Pa has excellent diagnostic accuracy for identifying ischemia post‐intervention. Using a hybrid strategy of post‐PCI Pd/Pa first, and FFR afterwards, if required, adenosine administration can be avoided in over 75% of physiologic assessments post intervention.
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BFBNIB, FZAB, GIS, IJS, KILJ, NLZOH, NUK, OILJ, SAZU, SBCE, SBMB, UL, UM, UPUK
Background Long-term outcomes after percutaneous coronary intervention (PCI) relate in part to residual ischemia in the treated vessel, as reflected by post-PCI fractional flow reserve (FFR). The ...strategy of FFR after PCI and treatment of residual ischemia-known as functionally optimized coronary intervention (FCI)-may be feasible and capable of improving outcomes. Methods and Results Feasibility and results of FCI using an optical-sensor pressure wire were prospectively evaluated in an all-comer population with 50% to 99% lesions and ischemic FFR (≤0.80; ClinicalTrials.gov identifier NCT03227588). FCI was attempted in 250 vessels in 226 consecutive patients. The PCI success rate was 99.6% (249/250 vessels). FCI technical success-that is, FFR before and after PCI and PCI itself using the FFR wire-was 92% (230/250 vessels). Incidence of residual ischemia in the treated vessel was 36.5%. Approximately a third of these vessels (34.5%, n=29) were considered appropriate for further intervention, with FFR increasing from 0.71±0.07 to 0.81±0.06 (
<0.001). Pressure wire pullback showed FFR ≤0.8 at distal stent edge was 7.9% and 0.7% proximal to the stent. FFR increase across the stent was larger in the ischemic than in the nonischemic group (0.06 interquartile range: 0.04-0.08 versus 0.03 interquartile range: 0.01-0.05;
<0.0001) compatible with stent underexpansion as a contributor to residual ischemia. Conclusions FCI is a feasible and safe clinical strategy that identifies residual ischemia in a large proportion of patients undergoing angiographically successful PCI. Further intervention can improve ischemia. The impact of this strategy on long-term outcomes needs further study.
Pseudoaneurysm (PSA) formation is a rare but well‐known complication of coronary stenting. It develops after a procedural perforation disrupts the integrity of the vessel wall but is contained by a ...single wall layer, usually pericardium, extravascular thrombosis and later fibrosis. Medical literature of PSA consists primarily of case reports. A systematic review of pseudoaneurysm after coronary stenting was performed to summarize its presentation, diagnostic imaging modalities, natural history, and management approaches. Clinical presentations range from asymptomatic to hemodynamic collapse, size from small to “giant,” and treatment approaches from surgical or percutaneous exclusion to “watchful waiting” and imaging surveillance. Based on current information, a management algorithm is provided recommending urgent to emergent exclusion for symptomatic PSA, elective exclusion for large and giant PSA, and “watchful waiting” and periodic imaging surveillance for small to moderate sized PSA.
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BFBNIB, FZAB, GIS, IJS, KILJ, NLZOH, NUK, OILJ, SAZU, SBCE, SBMB, UL, UM, UPUK
Objectives/Background
Resting coronary blood flow approximates flow with maximal vasodilation in very severe coronary stenosis. We studied the incidence of exhausted vasodilatory reserve by FFR, its ...clinical characteristics and long‐term prognosis after FFR guided percutaneous coronary intervention (PCI).
Methods
Consecutive patients undergoing FFR‐guided PCI for coronary stenosis with reduced resting blood flow (baseline Pd/Pa < 0.8) were included. Basal maximal vasodilation (BMV) was defined as less than 5% difference between resting Pd/Pa and FFR, that is, FFR‐baseline Pd/Pa < 0.05.
Results
Of 658 vessels that underwent FFR‐guided PCI in 602 patients, 151 vessels had resting blood flow in the ischemic range (baseline Pd/Pa ≤ 0.8) and were included in the analysis. Of these, 28 lesions in 28 patients met criteria for BMV (4.25% of the entire registry and 18.5% of those with the reduced basal coronary flow). Stenosis severity was a significant predictor of the presence of BMV. In long term follow‐up (median 106 ± 3.6 months), BMV was not associated with increased target vessel revascularization (TVR) or major adverse cardiac event compared to non‐BMV(OR 1.9, 95% CI 0.7–4.8, p‐value 0.2 and OR 1.3, 95% CI 0.75–2.5, p = 0.3, respectively).
Conclusion
Low baseline Pd/Pa that approximates fractional flow reserve (exhausted vasodilatory reserve) defines a subgroup of patients with severe coronary artery stenosis. Prognosis, when treated with PCI along with medical therapy, appears similar to those with intact vasodilatory reserve.
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BFBNIB, FZAB, GIS, IJS, KILJ, NLZOH, NUK, OILJ, SAZU, SBCE, SBMB, UL, UM, UPUK
Sodium-glucose cotransporter 2 inhibitor (SGLT2i) use is associated with improved cardiovascular and kidney outcomes. However, the magnitude and potential heterogeneity of effect across patients with ...varying types of cardiometabolic and kidney disease is unclear. To examine the effect of SGLT2i on cardiovascular and kidney outcomes among patients with type 2 diabetes mellitus (T2DM), and independent of T2DM status, among patients with heart failure (HF), and chronic kidney disease.
Medline, Embase, Cochrane library and scientific conferences were searched from inception till September 24, 2020 for randomized controlled trials comparing cardiovascular and kidney outcomes between SGLT2i and placebo. Random effects hazard ratios (HR) with 95% confidence intervals (CIs) were calculated.
Eight trials with a combined 59,747 patients were included. In the overall population, SGLT2i reduced the risk of all-cause mortality (HR 0.84; 95% CI 0.78-0.91), cardiovascular mortality (HR 0.84; 95% CI 0.76-0.93) hospitalization for HF (HR 0.69; 95% CI 0.64-0.74), myocardial infarction (HR 0.91; 95% CI 0.84-0.99), and composite kidney outcome (HR 0.62; 95% CI 0.56-0.70). There was no significant effect on the risk of stroke (HR 0.98; 95% CI 0.86-1.11). Results were consistent across subgroups stratified by diabetes and HF status. SGLT2i use was not associated with a greater risk of hypoglycemia (OR 0.92; 95% CI 0.84-1.01) or amputation (OR 1.25; 95% CI 0.97-1.62). There were 64 diabetic ketoacidosis events with SGLT2i use and 18 with placebo (OR 2.86; 95% CI 1.39-5.86).
In patients with cardiometabolic and kidney disease, SGLT2i improved cardiovascular and kidney outcomes, regardless of T2DM, HF, and/or CKD status. The magnitude of risk reduction was largest for hospitalization for HF and progression of kidney disease, more modest for mortality and MI and absent for stroke.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
Coronary pseudoaneurysm is a rare, potentially fatal, complication of coronary intervention. A challenging management case of a giant right coronary pseudoaneurysm is presented.
A 56-year-old man ...presented with an atypical presentation for ST-elevation myocardial infarction. Initial angiogram showed a crescent-shaped ostial lesion with probable connection to the aorta, which disappeared after placing a drug-eluting stent. A few hours later, patient was found to have staph aureus bacteraemia and infective endocarditis for which he received a prolonged antibiotic course. Patient presented a few weeks later with second degree heart block. Echocardiography showed a large cystic lesion adjacent to the right coronary cusp suspicious for a coronary pseudoaneurysm, which was confirmed with angiography. Attempts to treat it with a covered stent were unsuccessful and patient ultimately underwent surgical resection.
Coronary pseudoaneurysm develops when there is a contained breach of all three layers of the vessel. It may develop from direct iatrogenic trauma to the vessel wall but can be infectious in aetiology. The treatment approach remains uncertain due to limited evidence. Here, we present the diagnostic and technical challenges of managing such an uncommon entity and discuss an algorithm for management.
There is uncertainty and limited data regarding initiation of sodium-glucose cotransporter 2 (SGLT2) inhibitors among patients hospitalized with acute heart failure (AHF). This systematic review and ...meta-analysis aim to establish the efficacy and safety of SGLT2 inhibitors initiated in patients hospitalized for AHF.
PubMed/Medline, Embase, and Cochrane library were searched using the following terms: ("sglt2" and "acute heart failure") and ("sglt2" and "worsening heart failure") from inception till November 15th, 2021 for randomized controlled trials (RCTs) comparing the efficacy and safety of initiating an SGLT2 inhibitor compared with placebo in patients with AHF. Major cardiovascular and diabetes scientific meetings in 2021 were also searched for relevant studies. Prespecified efficacy outcomes were all-cause mortality, rehospitalization for heart failure, and improvement in Kansas City Cardiomyopathy Questionnaire (KCCQ) scale score. Prespecified safety outcomes were acute kidney injury (AKI), hypotension, and hypoglycemia. Random effects odds ratio (OR) and mean difference with 95% confidence intervals (CIs) were calculated.
Three RCTs with a total of 1831 patients were included. Initiation of SGLT2 inhibitors in patients with AHF reduced the risk of rehospitalization for heart failure (OR 0.52; 95% CI 0.42, 0.65) and improved Kansas City Cardiomyopathy Questionnaire scores (mean difference 4.12; 95% CI 0.1.89, 6.53). There was no statistically significant effect for initiation of SGLT2 inhibitors in patients with AHF on all-cause mortality (OR 0.70; 95% CI 0.46, 1.08). Initiation of SGLT2 inhibitors in patients with AHF did not increase the acute kidney injury (OR 0.76; 95% CI 0.50, 1.16), hypotension (OR 1.17; 95% CI 0.80, 1.71), or hypoglycemia (OR 1.51; 95% CI 0.86, 2.65).
Initiation of SGLT2 inhibitors in patients hospitalized for AHF during hospitalization or early post-discharge (within 3 days) reduces the risk of rehospitalization for heart failure and improves patient-reported outcomes with no excess risk of adverse effects.
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DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
We aimed to describe the impact of the vascular access used when patients are treated with primary percutaneous coronary intervention (PPCI) and to assess whether this translates into differences in ...angiographic outcomes. Patients with ST-elevation myocardial infarction who underwent PPCI were divided into 3 groups: successful radial access (RA), successful femoral access (FA), and Crossover (failed RA with need for bailout FA) groups. Vascular access–related time (VART) was defined as the delay in PPCI that can be attributed to vascular access–related issues. Study end point was the final corrected Thrombolysis In Myocardial Infarction frame count. Multivariable analysis was used to identify predictors of RA failure (RAF: FA + Crossover). We included 241 patients (RA, n = 172; FA, n = 49; Crossover, n = 20). Mean VART was longer in Crossover (10.3 8.8 to 12.4 minutes), relative to RA (4.1 3.2 to 5.5 minutes) and FA (4.6 3.4 to 8.4 minutes, p <0.001). A similar situation was found for time-to-first device (Crossover 22.5 20.3 to 32.0, RA 15.0 12.0 to 19.8; FA 17.9 13.5 to 22.3 minutes, p <0.001) and total procedure time (Crossover 60.3 51.6 to 71.5, RA 46.8 38.1 to 59.7, FA 52.3 41.9 to 74.7 minutes, p <0.001). No differences in corrected Thrombolysis In Myocardial Infarction frame count were observed (Crossover 26 18 to 32 frames, RA 24 18 to 32 frames, FA 25 16 to 34 frames, p = 0.625). Killip class IV (odds ratio OR 3.628, 95% confidence interval CI 1.098 to 11.981, p = 0.035), cardiopulmonary resuscitation before arrival (OR 3.572, 95% CI 1.028 to 12.407, p = 0.045), and glomerular filtration rate (OR 0.861, 95% CI 0.758 to 0.978, p = 0.021) were independent predictors of RA failure. In conclusion, in the setting of PPCI, radial-to-FA crossover can lead to VART delays that do not affect angiographic outcomes, in comparison with successful RA.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPCLJ, UPUK
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