Abstract
Background
Diabetes mellitus (DM) is a major risk factor for coronary artery disease (CAD) and PCI. Little is known about differences in PCI patterns and outcomes among DM patients across ...the globe.
Purpose
We aimed to determine differences in clinical outcomes and PCI practices among DM patients undergoing contemporary PCI across the continents.
Methods
e-Ultimaster is a prospective worldwide registry that enrolled 36; 671 patients and 1-year follow-up is currently available for 94,2% of the patients. All underwent PCI with a thin strut sirolimus-eluting stent with abluminal biodegradable polymer. This abstract focus on the DM population. Primary endpoint was target lesion failure (TLF) at 1-year (cardiac death, target vessel myocardial infarction (MI), clinically driven target lesion revascularization). A Clinical Event Committee adjudicated all endpoint-related adverse events. Patients were divided according to four regions of enrolment: Europe (EU), Asia (A), Africa/Middle East (A/ME), and Mexico/South America (M/SA).
Results
The prevalence of DM in e-Ultimaster ranged from 24.3% in E to 47.5% in A/ME. Among 9709 DM patients, 60% were enrolled in EU, 21% in A, 11% in A/ME and 8% in M/SA. Mean age ranged from 61.7 year in A as well as A/ME to 67.5 years in EU. The highest proportion of insulin requiring DM was found in A/ME (32.4%). Presentation with acute coronary syndromes ranged from 49% in A/ME to 55.6% in M/SA. The rate of primary endpoint (TLF) at one year was 4.2%. Definite/probable stent thrombosis (ST) occurred in 0.7% of at 1-year. Independent predictors of TLF included age, insulin-requiring DM, renal failure, previous PCI, number of lesions identified, presence of ACC/AHA type C lesions, treatment of left main lesions, treatment of bifurcation lesions, and number of stents implanted. Independent predictors of definite/probable ST included male gender, renal failure, history of MI, ST-elevated MI at presentation and number of lesions identified. TLF occurred in 2.1% in A/ME, 3.1% in A, 4.4% in M/SA and 5.0% in E. Definite/probable ST was lowest in A (0.3%) and A/ME (0.4%) and highest in M/SA and EU (both 0.9%).
Penetration of radial access ranged from 86.0% in EU to 56.9% in A/ME. The use of intravascular imaging ranged from 3.9% in EU to 30.3% in A. Use of dual antiplatelet therapy (DAPT), left at the discretion of the operator, was lowest in EU (92.9% at 3 months; 63.8% at 1 year) and highest in A (94.5% at 3 months; 82.6% at 1 year).
Conclusions
The analysis on more than 9000 DM patients treated with the same contemporary stent within a world-wide registry with defined inclusion/exclusion criteria and adjudicated clinical events showed favourable clinical outcomes at one year and detected major differences in patient characteristics, PCI pattern, DAPT prescription and clinical outcomes across continents. Data on the entire e-Ultimaster DM population will be available for ESC.
Funding Acknowledgement
Type of funding source: Private company. Main funding source(s): Terumo Europe
Diabetic mellitus (DM) patients with coronary artery disease (CAD) are at higher risk of cardiovascular events compared with non-DM individuals. While aggressive cardiovascular prevention and ...adequate blood glucose control remain cornerstones of therapy, the decision when and how to proceed to coronary revascularization in an individual DM patient should be based on the extent of CAD, ischaemic burden, ventricular function, as well as comorbidities. While in patients with stable symptoms, moderate CAD on coronary angiography and preserved left ventricular function a conservative strategy may be a valuable initial strategy, in patients with acute coronary syndromes (ACS) an early invasive approach should be favoured. The revascularization strategy for DM patients with complex multivessel CAD should be discussed within a heart team consisting of cardiologists, cardiac surgeons, and anaesthesiologists. In general, the threshold for coronary artery bypass surgery (CABG) should be lower for DM than for non-DM individuals. In patients undergoing percutaneous coronary intervention, the use of drug-eluting stents (DES) and-in the setting of ACS-of potent platelet inhibitors, such as prasugrel or ticagrelor, should be favoured. In the near future, multiple strategies may further favourably impact the prognosis of DM patients undergoing coronary revascularization. These include alternative antiplatelet agents such as thromboxane receptor inhibitors, the broad use of second generation DES, and possibly the implantation of bioresorbable stents. Coronary artery bypass surgery outcomes may also further improve by wide implementation of arterial revascularization, reduction in perioperative stroke by avoiding clamping of the aorta, reduction in wound infection by minimally invasive techniques, and optimization of post-operative medical management.
Background
Limited data are available on patients with chronic lung disease (CLD) presenting with acute myocardial infarction (AMI). We aimed to analyse baseline characteristics, treatment and ...outcome of those patients enrolled in the Swiss nationwide prospective AMIS Plus registry.
Methods
All AMI patients enrolled between January 2002 and December 2021 with data on CLD, as defined in the Charlson Comorbidity Index, were included. The primary endpoints were in‐hospital mortality and major adverse cardiac and cerebrovascular events (MACCE), defined as all‐cause death, reinfarction and cerebrovascular events. Baseline characteristics, in‐hospital treatments and outcomes were analysed using descriptive statistics and logistic regression.
Results
Among 53,680 AMI patients enrolled during this time, 5.8% had CLD. Compared with patients without CLD, CLD patients presented more frequently with non‐ST‐elevation myocardial infarction (MI) and type 2 MI (12.8% vs. 6.5%, p < 0.001). With respect to treatment, CLD patients were less likely to receive P2Y12 inhibitors (p < 0.001) and less likely to undergo percutaneous coronary interventions (68.7% vs. 82.5%; p < 0.001). In‐hospital mortality declined in AMI patients with CLD over time (from 12% in 2002 to 7.3% in 2021). Multivariable regression analysis showed that CLD was an independent predictor for MACCE (adjusted OR was 1.28 95% CI 1.07–1.52, p = 0.006).
Conclusion
Patients with CLD and AMI were less likely to receive evidence‐based pharmacologic treatments, coronary revascularization and had a higher incidence of MACCE during their hospital stay compared to those without CLD. Over 20 years, in‐hospital mortality was significantly reduced in AMI patients, especially in those with CLD.
We analysed patients with acute myocardial infarction (AMI) and chronic lung disease (CLD) over 20 years. Primary endpoints of this study were in‐hospital and major cardiac and cerebrovascular events. Patients with CLD were less likely to receive percutaneous coronary interventions than those without CLD. Non‐ST‐elevation myocardial infarction (MI) and type 2 MI were more likely to occur in patients with CLD. In‐hospital mortality and MACCE declined in AMI patients, especially in those with CLD over time.
BACKGROUND:Long-term trends of the incidence and outcome of cardiogenic shock (CS) patients are scarce. We analyze for the first time trends in the incidence and outcome of CS during a 20-year period ...in Switzerland.
METHODS AND RESULTS:The AMIS (Acute Myocardial Infarction in Switzerland) Plus Registry enrolls patients with acute myocardial infarction from 83 hospitals in Switzerland. We analyzed trends in the incidence, treatment, and in-hospital mortality of patients with CS enrolled between 1997 and 2017. The impact of revascularization strategy on outcome was assessed for the time period 2005 to 2017. Among 52 808 patients enrolled, 963 patients were excluded because of missing data and 51 842 (98%) patients remained for the purpose of the present analysis. Overall, 4090 patients (7.9%) with a mean age of 69.6±12.5 years experienced acute myocardial infarction complicated by CS. Overall, rates of CS declined from 8.7% to 7.3% between 1997 and 2017 (P for trend, <0.001; 1997–2006 versus 2007–2017). We observed a decrease in CS developing during hospitalization from 7.8% to 3.5% in the period 1997 to 2006 compared with 2007 to 2017 (P for trend, <0.001), which was partially offset by an increase in CS on admission between 2006 and 2017 (2.5% 1997–2006 to 4.6% 2007–2017; P for trend, <0.001). In-hospital mortality declined from 62.2% in 1997 to 36.3% in 2017 (P<0.001 for temporal trend). Percutaneous coronary intervention was the strongest independent predictor for survival (odds ratio, 0.36; CI, 0.28–045; P<0.001). Among patients with acute myocardial infarction and multivessel disease, multivessel percutaneous coronary intervention was associated with an increased risk of in-hospital mortality (odds ratio, 1.88; 95% CI, 1.59–2.21) and was an independent predictor for the development of CS during hospitalization (odds ratio, 1.93; 95% CI, 1.62–2.30).
CONCLUSIONS:Rates of CS declined between 1997 and 2017 driven by a reduction of CS developing during hospitalization. In-hospital mortality from CS declined from 62.8% (1997) to <40% (2017). Multivessel percutaneous coronary intervention was associated with an increased risk of mortality and the development of CS during hospitalization.
Aims
We investigated whether myeloid-related protein 8/14 complex (MRP8/14) expressed by infiltrating monocytes and granulocytes may represent a mediator and early biomarker of acute coronary ...syndromes (ACS).
Methods and results
Immunohistochemistry of coronary thrombi was done in 41 ACS patients. Subsequently, levels of MRP8/14 were assessed systemically in 75 patients with ACS and culprit lesions, with stable coronary artery disease (CAD), or with normal coronary arteries. In a subset of patients, MRP8/14 was measured systemically and at the site of coronary occlusion. Macrophages and granulocytes, but not platelets stained positive for MRP8/14 in 76% of 41 thrombi patients. In ACS, local MRP8/14 levels 22.0 (16.2-41.5) mg/L were increased when compared with systemic levels 13.4 (8.1-14.7) mg/L, P = 0.03. Systemic levels of MRP8/14 were markedly elevated 15.1 (12.1-21.8) mg/L, P = 0.001 in ACS when compared with stable CAD 4.6 (3.5-7.1) mg/L or normals 4.8 (4.0-6.3) mg/L. Using a cut-off level of 8 mg/L, MRP8/14 but not myoglobin or troponin, identified ACS presenting within 3 h from symptom onset.
Conclusion
In ACS, MRP8/14 is markedly expressed at the site of coronary occlusion by invading phagocytes. The occurrence of elevated MRP8/14 in the systemic circulation prior to markers of myocardial necrosis makes it a prime candidate for the detection of unstable plaques and management of ACS.
In the absence of randomized data, the optimal management of patients with severe carotid and coronary artery disease (CAD), especially those undergoing coronary bypass grafting (CABG), remains ...unsettled. As a general rule, in patients with multilevel atherosclerotic disease the symptomatic vascular discrict should be treated first. The entirely surgical approach with carotid endarterectomy (CEA) and CABG is associated with high event rates. Therefore, whenever in the work-up prior to cardiac surgery severe carotid disease is identified, the indication for CABG should be reassessed and the feasibility of percutaneous coronary intervention (PCI) as an alternative treatment should be explored. If PCI is not an option, carotid artery stenting (CAS) prior to open heart should be considered if the expertise is available. Although perioperative stroke is multifactorial and the value of revascularization of asymptomatic carotid disease prior to open heart surgery remains controversial, treatment of patients with severe bilateral carotid stenosis appears reasonable for perioperative stroke prevention. The aim of carotid revascularization in patient with unilateral severe carotid stenosis should more long-term stroke prevention than merely perioperative stroke reduction. The main advantage of CAS compared with CEA in patients with advanced CAD is the reduction of perioperative myocardial infarction, an event associated to long term mortality.
The history of carotid artery stenting (CAS) was made by brave men and women who believed in a less invasive treatment modality than carotid endarterectomy (CEA) to treat carotid stenosis despite the ...risk--which was obviously present also with surgery--to cause a stroke, the very event that the procedure aimed to prevent. The bulky equipment, the lack of knowledge about the appropriate antithrombotic regimen, and the impossibility at early stage to influence distal embolization added to the pressure on the investigators. At times, the confrontation with the surgical community has been hard. The technique evolved with the inputs of multiple disciplines on both sides of the Atlantic including radiology, cardiology, neuroradiology and vascular surgery. Major breakthrough included the use of dual antiplatelet therapy, of self-expanding stents and of emboli protection devices. Unfortunately, randomized investigations against surgery started too early, in a phase in which the cas technique was not yet mature and the investigators lacked the necessary experience in terms of catheter skills and appropriate patient selection.
Aims To assess the efficacy of platelet glycoprotein IIb/IIIa inhibitors in patients with acute coronary syndromes primarily medically managed. Methods and Results We performed a meta-analysis of the ...randomized clinical trials of platelet glycoprotein IIb/IIIa inhibitor therapy in the medical management of non-ST-elevation acute coronary syndromes. Among 29570 patients, IIb/IIIa integrin blockade was associated with a reduction in death or non-fatal myocardial infarction at 30 days, from 11·5% to 10·7% (odds ratio 0·91,P =0·02). Patients undergoing percutaneous coronary intervention during index hospitalization sustained a greater reduction in ischaemic events (odds ratio 0·82, P=0·01) than patients medically managed (odds ratio 0·95, P=0·27). Among patients undergoing intervention, the benefit was more pronounced if the procedure was performed during glycoprotein IIb/IIIa inhibitor infusion (odds ratio 0·74; P=0·02), than if revascularization was performed after drug discontinuation (odds ratio 0·87,P =0·17). Conclusion This analysis, including the entire large-scale trial experience of intravenous glycoprotein IIb/IIIa inhibitors in patients with acute coronary syndromes primarily medically managed, demonstrates an overall significant, albeit moderate, reduction in 30-day death or myocardial infarction associated with therapy. Although not based on a prospectively defined hypothesis, the findings suggest a gradient of benefit conferred by these agents depending on the revascularization strategy used. Copyright 2002 The European Society of Cardiology. Published by Elsevier Science Ltd. All rights reserved.
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