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Coronary Artery Plaque Phenotype and 5-Year Clinical Outcomes in Older Patients with Non-ST Elevation Acute Coronary Syndrome.
Full text linkBACKGROUND
Lesions with thin-cap fibroatheroma (TCFA), small luminal area and large plaque burden (PB) have been considered at high risk of cardiovascular events. Older patients were not represented in studies which demonstrated correlation between clinical outcome and plaque characteristics. This study aims to investigate the prognostic role of high-risk plaque characteristics and long-term outcome in older patients presenting with non-ST elevation acute coronary syndrome (NSTEACS).
METHODS
This study recruited older patients aged 75 years with NSTEACS undergoing virtual-histology intravascular ultrasound (VH-IVUS) imaging from the Improve Clinical Outcomes in high-risk patieNts with acute coronary syndrome (ICON-1). Primary endpoint was the composite of major adverse cardiovascular events (MACE) consisting of all-cause mortality, myocardial infarction (MI), and any revascularisation. Every component of MACE and target vessel failure (TVF) including MI and any revascularisation were considered as secondary endpoints.
RESULTS
Eighty-six patients with 225 vessels undergoing VH-IVUS at baseline completed 5-year clinical follow-up. Patients with minimal lumen area (MLA) 4 demonstrated increased risk of MACE (hazard ratio [HR] 2.37, 95% confidence interval [CI] 1.00-5.59, p = 0.048) with a worse event-free survival (Log Rank 4.17, p = 0.041) than patients with MLA 4 . Patients with combination of TCFA, MLA 4 and PB 70% showed high risk of MI (HR 5.23, 95% CI 1.05-25.9, p = 0.043). Lesions with MLA 4 had 6-fold risk of TVF (HR 6.16, 95% CI 1.24-30.5, p = 0.026).
CONCLUSIONS
Small luminal area appears as the major prognostic factor in older patients with NSTEACS at long-term follow-up. Combination of TCFA, MLA 4 and PB 70% was associated with high risk of MI.
CLINICAL TRIAL REGISTRATION
NCT01933581
The role of physiology in the contemporary management of coronary artery disease
No full textCoronary physiology assessment, including epicardial and microvascular investigations, is a fundamental tool in the contemporary management of patients with coronary artery disease. Coronary revascularisation guided by functional evaluation has demonstrated superiority over angiography-only-guided treatment. In patients with chronic coronary syndrome, revascularisation did not demonstrate prognostic advantage in terms of mortality over optimal medical therapy (OMT). However, revascularisation of coronary stenosis, which induces myocardial ischaemia, has demonstrated better outcome than OMT alone. Pressure wire (PW) or angiography-based longitudinal coronary physiology provides a point-by-point analysis of the vessel to detect the atherosclerotic pattern of coronary disease. A careful evaluation of this disease pattern allows clinicians to choose the appropriate management strategy.Patients with diffuse disease showed a twofold risk of residual angina after percutaneous coronary intervention (PCI) than those with focal disease. Therefore, OMT alone or coronary artery bypass graft might be considered over PCI. In addition, the post-PCI physiological assessment aims to optimise the result revealing residual myocardial ischaemia. Improvement in post-PCI PW or angiography-based functional indices has been associated with better quality of life and reduced risk of cardiac events and residual angina. Therefore, the information obtained from coronary physiology allows for an optimised treatment strategy, which ultimately leads to improve patient's prognosis and quality of life. This review provides an overview of the latest available evidence in the literature regarding the use of functional assessment of epicardial coronary stenosis in different settings in the contemporary patient-tailored management of coronary disease
Tailoring antiplatelet therapy in older patients with coronary artery disease
No full textThe older population represents a unique subset of patients due to a higher rate of comorbidities and risk factors, which can lead to a higher rate of ischemic and bleeding events. As a result, older adults are mainly underrepresented or excluded from randomized trials. Although the advancement in the percutaneous coronary intervention field with the development of new technologies, techniques, and potent antiplatelet therapy led to a reduction of ischemic risk, there is still a concern regarding bleeding hazards. Apart from the global utilization of less invasive trans-radial approach and proton pump inhibitors to reduce bleeding risk, proper tailoring of antiplatelet therapy in the older person is imperative. So far, several antiplatelet drugs have been introduced in different clinical scenarios, with dual antiplatelet therapy (combination of acetylsalicylic acid and P2Y12 inhibitor) recommended after percutaneous coronary intervention. The decision on the choice of antiplatelet drug and the DAPT duration is challenging and should be based on the relationship between ischemia and bleeding with the purpose of reducing ischemic events but not at the expense of increased bleeding complications. This is particularly important in the older population, where the evidence is obscure. The main objective of this review is to summarize the available evidence on contemporary antiplatelet therapy and different approaches of de-escalation strategies in older patients after percutaneous coronary intervention
Shedding Light on Treatment Options for Coronary Vasomotor Disorders: A Systematic Review
No full textPurpose Coronary vasomotor dysfunction embraces two specific clinical entities: coronary (micro)vascular spasm and microvascular dysfunction. The clinical manifestations of these entities are respectively called vasospastic angina (VSA) and microvascular angina (MVA). Over the years, these diseases have become more and more prominent and several studies aimed to investigate the best diagnostic and therapeutic strategies. Patients with coronary vasomotor disorders are often undertreated due to the absence of evidence-based guidelines. The purpose of this overview is to illustrate the various therapeutic options available for the optimized management of these patients. Methods A Medline search of full-text articles published in English from 1980 to April 2022 was performed. The main analyzed aspects of vasomotor disorders were treatment options. We also performed research on "Clinicaltrial.gov" for ongoing trials. Conclusion Coronary (micro)vascular spasm and microvascular dysfunction are clinical entities characterized by high prevalence and clinical representation. Several therapeutic strategies, both innovative and established, are available to optimize treatment and improve the quality of life of these patients
Cognitive impairment and outcomes in older adults with non-ST-elevation acute coronary syndrome
No full textObjective This study aimed to explore the prognostic impact of cognitive impairment on the long-term risk of major adverse cardiovascular events (MACEs) in older patients with non-ST-elevation acute coronary syndrome (NSTEACS) undergoing invasive treatment.Methods Patients aged >= 75 years with NSTEACS undergoing an invasive strategy were included in the multicentre prospective study (NCT01933581). Montreal Cognitive Assessment was used to evaluate cognitive status at baseline (scores >= 26 classified as normal, <26 as cognitive impairment). Long-term follow-up data were obtained from electronic patient care records. The primary endpoint was MACE as a composite of all-cause deaths, reinfarction, stroke/transient ischaemic attack, urgent revascularisation and significant bleeding.Results 239 patients with baseline cognitive assessment completed long-term follow-up. Median age was 80.9 years (IQR 78.2-83.9 years) and 62.3% were male. On 5-year follow-up, there was no significant difference in the occurrence of MACE between the cognitively impaired group and the normal cognition group (p=0.155). Cognition status was not associated with MACE (HR 1.37 (95% CI 0.96 to 1.95); p=0.082). However, there was significantly more deaths (p=0.005) in those with cognitive impairment. Kaplan-Meier survival analysis (log-rank p=0.003) and Cox regression analysis (aHR 1.85 (95% CI 1.11 to 3.08); p=0.018) revealed increased risk of all-cause mortality, even after adjusting for frailty and GRACE (Global Registry of Acute Coronary Events) score.Conclusion Cognitive impairment in older patients with NSTEACS undergoing an invasive strategy was associated with long-term all-cause mortality. Routine cognitive screening may aid risk stratification and further studies are needed to identify how this should influence management strategies and individual decision-making in this patient group
Percutaneous revascularization in non-ST-elevation acute coronary syndromes: complete or incomplete?
No full textNon-ST-elevation myocardial infarction with multivessel coronary disease is increasing in patients presenting with acute coronary syndrome (ACS) and it is associated with a high rate of mortality. Complete revascularization may reduce major adverse cardiac events in patients with ACS. However, the preferred revascularization strategies (complete vs incomplete) of non-culprit lesions in this setting, as well as the correct timing of revascularization are still matters of debate. This is mostly related to the heterogeneity of patients with this clinical presentation, who are often older and affected by multiple comorbidities. The present review aims to evaluate this topic highlighting the pros and cons of complete revascularization according to anatomical or functional and imaging evaluation and based on timing and patient's clinical phenotype
[Three-year outcomes of transcatheter vs surgical aortic valve replacement in low-risk patients with severe aortic stenosis]
No full textSCOPO DELLO STUDIO
Valutare i risultati clinici ed ecocardiografici a 3 anni dello studio Evolut Low Risk che ha incluso pazienti con stenosi aortica severa sintomatica e basso rischio operatorio (STS score <3%) randomizzati ad intervento di sostituzione valvolare aortica chirurgica (SAVR) o impianto transcatetere di valvola aortica (TAVI).
POPOLAZIONE E CENTRI COINVOLTI
1414 pazienti sono stati arruolati nello studio tra il 2016 e il 2019 in 86 centri a livello mondiale: 684 soggetti trattati con SAVR e 730 con TAVI.
INTERVENTO
Randomizzazione a SAVR o TAVI con impianto di valvola sovra-anulare auto-espandibile (CoreValve o Evolut R/PRO).
OUTCOME PRINCIPALI
• Endpoint primario prespecificato: composito di mortalità per tutte le cause o ictus disabilitante a 3 anni.
• Endpoint secondari: impianto di pacemaker, endocardite, trombosi della valvola, riospedalizzazione per disfunzione valvolare, mismatch protesi-paziente, leak paravalvolare, performance della valvola mediante analisi dei dati ecocardiografici (gradiente medio ed area effettiva dell’orifizio [EOA]), qualità della vita mediante classe funzionale NYHA e Kansas City Cardiomyopathy Questionnaire.
RISULTATI
L’età media della popolazione era di 74 anni con il 35% di soggetti di sesso femminile; l’STS score medio era dell’1.9%. Di seguito i principali risultati a 3 anni di follow-up:
• Endpoint primario composito: TAVI 7.4% vs SAVR 10.4 % (p=0.051), con un trend costante
a favore della TAVI negli anni (Δ 1 anno 1.8%, Δ 2 anni 2.0%, Δ 3 anni 2.9%).
• Significativa la differenza tra i gruppi per incidenza di fibrillazione atriale (TAVI 13.1% vs SAVR
40.0%, p<0.001) ed impianto di pacemaker (TAVI 23.2% vs SAVR 9.1%, p<0.001).
• Rari in entrambi i gruppi gli eventi di reintervento valvolare aortico (TAVI 1.0% vs SAVR 0.9%) e
di trombosi subclinica (TAVI 0.4% vs SAVR 0.5%) o clinica (TAVI 0.3% vs SAVR 0.2%) della protesi.
• Performance della valvola: i pazienti del gruppo TAVI presentavano gradiente transvalvolare
medio significativamente inferiore (TAVI 9.1 mmHg vs SAVR 12.1 mmHg; p<0.001) e una maggiore
EOA (TAVI 2.2 cm2 vs SAVR 2.0 cm2, p<0.001).
• Mismatch protesi-paziente ≥ moderato: TAVI 10.6% vs SAVR 25.1% (p<0.001).
• Leak paravalvolare: tra 1 e 3 anni la severità dei leak paravalvolari non è incrementata, con
differenza significativa tra i due gruppi per il leak lieve (TAVI 20.3% vs SAVR 2.5% p<0.001), ma non per le forme di grado moderato/severo (TAVI 0.9% vs SAVR 0.2%, p=0.16)
Non-invasive vascular measures as prognostic predictors for older patients with non-ST elevation acute coronary syndrome
No full textBackgroundAdverse cardiac events are common in older patients with non-ST elevation acute coronary syndrome (NSTEACS), yet prognostic predictors are still lacking. This study investigated the long-term prognostic significance of non-invasive measures including endothelial function, carotid intima-media thickness (CIMT), and vascular stiffness in older NSTEACS patients referred for invasive treatment.MethodsNSTEACS patients aged 75 years and older recruited to a multicentre cohort study (NCT01933581) were assessed for baseline endothelial function using endoPAT logarithm of reactive hyperemia index (LnRHI), CIMT using B-mode ultrasound, and vascular stiffness using carotid-femoral pulse wave velocity (cfPWV). Long-term outcomes included major adverse cardiovascular events (MACE), a composite of death, reinfarction, urgent revascularization, stroke/transient ischemic attack, and significant bleeding.ResultsRecruitment resulted in 214 patients assessed for LnRHI, 190 patients assessed for CIMT and 245 patients assessed for cfPWV. For LnRHI group (median follow-up 4.73 years [IQR: 1.41-5.00]), Cox regression analysis revealed a trend towards increased risk of MACE (HR: 1.24 [95% CI: 0.80-1.93]; P = 0.328) and mortality (HR: 1.49 [95% CI: 0.86-2.59]; P = 0.157), but no significance was reached. No difference for other components of MACE was found. For CIMT group (median follow up 4.74 years [IQR: 1.55-5.00]), no statistically significant difference in MACE was found (HR: 0.92 [95% CI: 0.53-1.59]; P = 0.754). Similarly, for cfPWV group (median follow-up 4.96 years [IQR: 1.55-5.00]), results did not support prognostic significance (for MACE, HR: 0.95 [95% CI: 0.65-1.39]; P = 0.794).ConclusionEndothelial function, CIMT and vascular stiffness were proven unsuitable as strong prognostic predictors in older patients with NSTEACS.Clinical trial registration:NCT01933581
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