Faculty Bibliography

BACKGROUND:In patients with diabetes mellitus (DM) and high bleeding risk (HBR) undergoing percutaneous coronary intervention (PCI), the optimal duration of dual antiplatelet therapy (DAPT) remains uncertain. AIMS/OBJECTIVE:We sought to compare early DAPT discontinuation in DM and non-DM patients enrolled in the prospective XIENCE Short DAPT programme. METHODS:The effects of 1- versus 3-month DAPT on ischaemic and bleeding outcomes were compared using propensity score stratification. The primary endpoint was a composite of all-cause death or myocardial infarction (MI) at 1 year. The incidence of Bleeding Academic Research Consortium (BARC) Type 2 to 5 bleeding was the key secondary endpoint. RESULTS:Out of 3,352 included patients, 1,299 (38.8%) had DM; diabetic patients had a higher 1-year incidence of death or MI (DM vs non-DM: 10.1% vs 6.6%) and similar BARC 2-5 bleeding (DM vs non-DM: 9.5% vs 9.2%). With 1- versus 3-month DAPT, the incidence of death or MI did not statistically differ in DM patients (adjusted hazard ratio [adjHR] 0.70, 95% confidence interval [CI]: 0.47-1.05) and non-DM patients (adjHR 1.26, 95% CI: 0.87-1.81), although heterogeneity by DM status was evident (p for interaction=0.015). BARC 2-5 bleeding was numerically lower with 1-month DAPT in both groups (DM: adjHR 0.67, 95% CI: 0.45-1.01; non-DM: adjHR 0.78, 95% CI: 0.56-1.07; p for interaction=0.973). CONCLUSIONS:Among HBR patients with DM undergoing PCI, 1-month DAPT, as compared to 3-month DAPT, was not associated with an excess of fatal or non-fatal MI and even reduced the occurrence of bleeding. These findings should be interpreted in the context of a predominantly stable patient population with low procedural complexity and may not be generalisable to higher-risk cases.

Blood pressure variability (BPV) predicts cardiovascular events independent of mean blood pressure. BPV is defined as short-term (24-h), medium or long- term (weeks, months or years). Standard deviation, coefficient of variation and variation independent of the mean have been used to quantify BPV. High BPV is associated with increasing age, diabetes, smoking and vascular disease and is a consequence of premature ageing of the vasculature. Long-term BPV has been incorporated into cardiovascular risk models (QRISK) and elevated BPV confers an increased risk of cardiovascular outcomes even in subjects with controlled blood pressure. Long-acting dihydropyridine calcium channel blockers and thiazide diuretics are the only drugs that reduce BPV and for the former explains their beneficial effects on cardiovascular outcomes. We believe that BPV should be incorporated into blood pressure management guidelines and based on current evidence, long-acting dihydropyridines should be preferred drugs in subjects with elevated BPV.

INTRODUCTION/BACKGROUND:This study explores the implementation and outcomes of catheter-based thrombectomy (CBT) for acute pulmonary embolism (PE) within a safety-net hospital (SNH), addressing a critical gap in the literature concerning CBT in underserved and vulnerable populations. METHODS:This is a retrospective study of patients undergoing CBT between October 2020 and January 2024 at a SNH. The primary outcome was 30-day all-cause mortality. RESULTS:A total of 107 patients (47.6 % female, mean age 58.4 years) underwent CBT for acute PE, with 23 (21.5 %) high-risk and 84 (78.5 %) intermediate-risk PE. Demographically, 64 % identified as Black, 10 % White, 19 % Hispanic or Latino, and 5 % Asian. In terms of insurance coverage, 50 % had private insurance or Medicare, 36 % had Medicaid, and 14 % were uninsured. Notably, 67 % of the patients resided in high poverty rate zip codes and 11 % were non-citizen non-residents. Over a median follow up period of 30 days, 6 (5.6 %) patients expired (all high-risk PE), 3 of whom presented with cardiac arrest. No patients who presented with intermediate-risk PE died at 30 days. There was no difference in 30-day mortality based on race, insurance type, poverty level or citizenship status. CONCLUSION/CONCLUSIONS:Our study findings reveal no disparities in access or outcomes to CBT at our SNH, emphasizing the feasibility and success of implementing PERT and CBT at a SNH, offering a potential model to address healthcare disparities in acute PE on a broader scale.

BACKGROUND:This study examined stress echocardiography (SE) in relation to coronary artery anatomy, and outcome in subjects randomized in the International Study of Comparative Health Effectiveness with Medical and Invasive Approaches (ISCHEMIA) Trial. METHODS:Of 5,179 patients randomized to initial invasive or conservative strategy, SE was performed in 1,079. Coronary computed tomographic angiogram (CCTA) excluded left main disease and quantified coronary lesions. Degree of ischemia was defined by number of segments with stress-induced wall motion abnormalities (WMA) (mild < 3, moderate = 3 and severe > 3). Transient ischemic dilation (TID) was defined as a 10% increase in stress left ventricular (LV) end systolic volume. Primary end point was a composite of cardiovascular death (CVD), nonfatal myocardial infarction (MI), or hospitalization for unstable angina, heart failure, or resuscitated cardiac arrest. RESULTS:On CCTA, 607/715 (84%) with CCTA evaluable for ≥70% lesion had one such lesion. Features associated with coronary lesions ≥ 70% were number of ischemic/infarcted segments, 3 or more ischemic segments in the anterior territory and inability to augment LV ejection fraction 10 percentage points . TID, present in 28.5%, was significantly associated with severity of ischemia. For every 0.10 increase in peak wall motion score index (WMSI), there was 12% increased risk of CVD or MI (adjusted HR=1.12 (95% CI: 1.04, 1.21), p=0.003. CONCLUSION/CONCLUSIONS:In patients with chronic coronary disease and moderate or severe myocardial ischemia receiving contemporary therapies, stress echocardiography identified subjects with significant CAD and WMSI provided prognostic value.

BACKGROUND:In the ISCHEMIA Trial, 5179 patients with stable coronary disease were randomized to initial invasive or conservative management. METHODS:PCI was recommended with a SYNTAX score 0-22 (low) and CABG with a SYNTAX score ≥33 (high). Either could be recommended for intermediate scores. The composite primary outcome was cardiovascular death, MI, or hospitalization for unstable angina, heart failure, or resuscitated cardiac arrest. There were two cohorts in this analysis. The descriptive cohort included patients who underwent CABG or PCI within 180 days of randomization and had no primary outcome before revascularization. The comparative cohort excluded participants with prior CABG, single vessel disease, SYNTAX score ≥ 45, and without core laboratory assessment. We focused on the intermediate (23-32) SYNTAX comparative group for which either CABG or PCI could be recommended. RESULTS:For 1935 patients in the descriptive cohort (485 CABG, 1450 PCI), the SYNTAX score was 27.3 ± 11.0 in the CABG group and 15.3 ± 8.6 in the PCI group, p<0.0001. Most patients with low SYNTAX scores underwent PCI (87.1%), while most with high SYNTAX scores underwent CABG (72.6%). For the 1203 patients (385 CABG, 818 PCI) in the entire comparative cohort, the adjusted 4-year primary event rate was 14.5% for CABG and 13.2% for PCI (difference 1.3%, 95% CI, -4.9% to 7.7%). For the 346 patients (163 CABG, 183 PCI) in the intermediate SYNTAX group, the adjusted 4-year primary event rate was 10.6% for CABG and 18.3% for PCI (difference -7.6%, 95% CI, -16.1% to 0.9%). CONCLUSIONS:Selection of revascularization method resulted in more PCI in the low SYNTAX group and more CABG in the high SYNTAX group. There was no statistical evidence of a difference between PCI and CABG in the intermediate SYNTAX group but the CIs are broad, reflecting uncertainty. GOV IDENTIFIER/UNASSIGNED:NCT01471522; https://clinicaltrials.gov/ct2/show/NCT01471522.

BACKGROUND:Despite the increasing use of catheter-based therapies (CBTs) for acute pulmonary embolism (PE), evidence is limited regarding the long-term outcome. OBJECTIVES/OBJECTIVE:We aimed to investigate the efficacy of CBT for high- and intermediate-risk PE in older adults. METHODS:We included Medicare fee-for-service beneficiaries aged 65 to 99 years admitted for PE from 2017 to 2020 and compared in-hospital and long-term outcomes between patients treated with and without CBT. Propensity score matching weight and instrumental variable analyses were implemented. RESULTS:We included 6,742 and 23,750 patients with high-risk and intermediate-risk PE, of which 11.4% and 15.1% patients were treated with CBT. In high-risk PE, patients treated with CBT, compared with those without, experienced lower in-hospital death (29.0% vs 43.9%; adjusted OR [aOR]: 0.73; 95% CI: 0.61-0.87) and 3-year mortality (45.7% vs 65.5%; adjusted HR: 0.76; 95% CI: 0.67-0.85) but higher intracranial hemorrhage (2.1% vs 1.0%; aOR: 2.29; 95% CI: 1.18-4.44). In intermediate-risk PE, we found no evidence that the incidence of in-hospital death differed between the 2 groups (3.1% vs 4.1%; aOR: 0.93; 95% CI: 0.75-1.16), but patients treated with CBT experienced lower 3-year mortality (14.9% vs 30.3%; adjusted HR: 0.69; 95% CI: 0.63-0.75) and higher incidence of intracranial hemorrhage (0.5% vs 0.3%; aOR: 2.04; 95% CI: 1.17-3.55). The association between the use of CBT and lower 3-year mortality was consistent in the instrumental variable analysis. CONCLUSIONS:Among older adults with high-risk or intermediate-risk PE, patients treated with CBT experienced lower mortality over the follow-up of up to 3 years, but higher risk of in-hospital bleeding complications.

BACKGROUND:Acute pulmonary embolism (PE) is a common cause of cardiovascular morbidity and mortality. Catheter-based therapies (CBT) are emerging technologies that provide reperfusion for patients with PE. However, the optimal timing of these interventions from initial presentation is unknown. AIMS/OBJECTIVE:This study aimed to determine whether the timing of CBT affects outcomes among patients with acute PE managed with CBT. METHODS:This was a retrospective cohort study of patients with PE who underwent CBT and were included in the Nationwide Readmissions Database between January 2017 and December 2020. Patients who underwent early CBT (≤1 day from admission) were compared with those who underwent delayed CBT (>1 day). The primary outcome was death at 90 days, and secondary outcomes included 90-day readmissions. Propensity scores were estimated using logistic regression, and propensity score weighting (PSW) was utilised to compare outcomes between early and delayed CBT. Cox proportional hazards modelling was used to estimate the risk of primary and readmission outcomes. RESULTS:A total of 12,137 patients were included: 1,992 (16.4%) had high-risk PE, and 1,856 (15.3%) were treated with delayed CBT. After PSW, early CBT was associated with a lower risk of 90-day death in both intermediate-risk (hazard ratio [HR] 0.55, 95% confidence interval [CI]: 0.46-0.66) and high-risk (HR 0.89, 95% CI: 0.80-0.99) PE. Early CBT was associated with lower rates of all-cause readmission in patients with intermediate-risk PE (HR 0.86, 95% CI: 0.78-0.95) and in those with high-risk PE (HR 0.84, 95% CI: 0.69-1.05). CONCLUSIONS:Among patients with intermediate- or high-risk PE, early CBT was associated with a lower risk of 90-day death and readmission. A further prospective study on the optimal timing for reperfusion using CBT is needed.