Faculty Bibliography

BACKGROUND:The ISCHEMIA-CKD (International Study of Comparative Health Effectiveness with Medical and Invasive Approaches-Chronic Kidney Disease) trial found no advantage to an invasive strategy compared to conservative management in reducing all-cause death or myocardial infarction (D/MI). However, the prognostic influence of angiographic coronary artery disease (CAD) burden and ischemia severity remains unknown in this population. We compared the relative impact of CAD extent and severity of myocardial ischemia on D/MI in patients with advanced chronic kidney disease (CKD). METHODS:Participants randomized to invasive management with available data on coronary angiography and stress testing were included. Extent of CAD was defined by the number of major epicardial vessels with ≥50% diameter stenosis by quantitative coronary angiography. Ischemia severity was assessed by site investigators as moderate or severe using trial definitions. The primary endpoint was D/MI. RESULTS:Of the 388 participants, 307 (79.1%) had complete coronary angiography and stress testing data. D/MI occurred in 104/307 participants (33.9%). Extent of CAD was associated with an increased risk of D/MI (P < .001), while ischemia severity was not (P = .249). These relationships persisted following multivariable adjustment. Using 0-vessel disease (VD) as reference, the adjusted hazard ratio (HR) for 1VD was 1.86, 95% confidence interval (CI) 0.94 to 3.68, P = .073; 2VD: HR 2.13, 95% CI 1.10 to 4.12, P = .025; 3VD: HR 4.00, 95% CI 2.06 to 7.76, P < .001. Using moderate ischemia as the reference, the HR for severe ischemia was 0.84, 95% CI 0.54 to 1.30, P = .427. CONCLUSION/CONCLUSIONS:Among ISCHEMIA-CKD participants randomized to the invasive strategy, extent of CAD predicted D/MI whereas severity of ischemia did not.

This case series shows how the 2021 ACC/AHA/SCAI guideline for coronary artery revascularization can be used to decide between revascularization or optimal medical therapy to reduce mortality or cardiovascular events in selected subsets of patients with stable ischemic heart disease and complex coronary disease with or without left ventricular dysfunction. (Level of Difficulty: Advanced.).

Recent meta-analyses investigating dual antithrombotic therapy (DAT) versus triple antithrombotic therapy (TAT) among patients who require oral anticoagulants especially with atrial fibrillation (AF) undergoing percutaneous coronary intervention (PCI) raised the concern of stent thrombosis (ST) and myocardial infarction (MI), however, these meta-analyses did not include all randomized trials who require oral anticoagulants. We aimed to investigate the efficacy of DAT versus TAT in these patients undergoing PCI. Our data showed the risk of ST was not significantly different in DAT vs. TAT (HR [95%CI]: 1.50 [0.97-2.34], p = .07; I

BACKGROUND:The initial wave of the coronavirus disease 2019 (COVID-19) pandemic resulted in an influx of patients with acute viral illness and profound changes in healthcare delivery in New York City. The impact of this pandemic on the presentation and invasive management of acute myocardial infarction (MI) is not well described. METHODS:This single-center retrospective study compared patients with MI who underwent invasive coronary angiography at New York University from March-April 2020, during the peak of the first wave of the pandemic, with those presenting in March-April 2019. RESULTS:Only 35 patients with MI underwent angiography during the study period in 2020 vs 109 patients in 2019. No differences in comorbidities or baseline medications were identified. The proportion of patients with ST-segment elevation MI (STEMI) was higher in 2020 than in 2019 (48.6% vs 24.8%, respectively; P=.01). Median peak troponin concentration was higher (14.5 ng/mL vs 2.9 ng/mL; P<.01) and left ventricular ejection fraction was lower (43.34% vs 51.1%; P=.02) during the pandemic. Among patients with non-STEMI, time from symptom onset to presentation was delayed in 2020 compared with 2019 (median, 24 hours vs 10 hours; P=.04). CONCLUSION/CONCLUSIONS:There was a dramatic decrease in the number of patients with MI undergoing coronary angiography during the first wave of the COVID-19 pandemic. Of those who presented, patients tended to seek care later after symptom onset and had excess myocardial injury. These data indicate a need for improved patient education to ensure timely cardiovascular care during public health emergencies.

Background: The role of invasive management compared with medical management in patients with non-ST-segment elevated myocardial infarction (NSTEMI) and advanced chronic kidney disease (CKD) is uncertain, given the increased risk of procedural complications in patients with CKD. We examined the efficacy and safety of invasive management in patients with NSTEMI-CKD compared with medical management.
Method(s): We identified NSTEMI and CKD stages 3, 4, 5, end-stage renal disease (ESRD) admissions using administrative codes from the Nationwide Readmission Database 2016 to 2018. Invasive approach was defined as coronary angiography with or without revascularization procedure, and other patients were categorized into medical management. Major adverse cardiovascular events (MACE) outcome was a composite of myocardial infarction (MI), heart failure, stroke, or death at 6 months. The safety outcome was a composite of acute kidney injury (AKI), vascular complication, major bleeding, or stroke at 6 months. We matched 2 groups using propensity score and applied Cox-proportional hazard regression to compute hazard ratio (HR) and 95% confidence interval (CI).
Result(s): Of 133,642 patients with NSTEMI and CKD, 62.3% were treated with the invasive management, whereas 37.7% patients were managed medically. Invasive management was associated with a lower hazard of MACE (CKD 3: HR: 0.73 [95% CI: 0.69-0.76, P < 0.001]; CKD 4: HR: 0.75 [95% CI: 0.70-0.81, P < 0.001]; CKD 5: HR: 0.67 [95% CI: 0.54-0.84, P < 0.001]; ESRD: HR: 0.80 [95% CI: 0.75-0.86, P < 0.001]) without increasing safety outcomes (CKD 3: HR: 0.99 [95% CI: 0.89-1.10, P = 0.822]; CKD 4: HR: 1.07 [95% CI: 0.91-1.26, P = 0.406]; CKD 5: HR: 0.91 [95% CI: 0.55-1.49, P = 0.698]; ESRD: HR: 1.14 [95% CI: 0.93-1.41, P = 0.213]) at 6 months in all CKD groups compared with medical management. Similarly, invasive management was associated with reduced hazard of mortality across all the CKD groups compared with medical management (Figures 1A and 1B). [Formula presented]
Conclusion(s): The benefits of invasive management remained significantly higher in patients with NSTEMI and CKD compared with medical management, without any difference in safety. Categories: CORONARY: Acute Myocardial Infarction
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Background: Alport syndrome is a rare and serious inherited form of CKD affecting as many as 60,000 persons in the US with no specific therapies approved for its treatment.
Method(s): An international, multicenter, double-blind, placebo-controlled, randomized Phase 3 trial (CARDINAL; NCT03019185) evaluated the safety and efficacy of bardoxolone methyl (Bard) in patients with Alport syndrome 12 to 70 years of age with baseline eGFR 30-90 mL/min/1.73 m² and UACR<= 3500mg/g. As an exploratory endpoint, the trial assessed patient global impression of change (PGIC), a non-disease specific 7-point scale that asks patients to rate how much their illness has changed as very much/much/minimally improved (1, 2, and 3 pts), no change (4 pts), or minimally/much/ very much worse (5, 6, and 7 pts) after 48 and 100 weeks of treatment.
Result(s): A total of 157 patients were randomized to Bard (n=77) or placebo (n=80). In addition to significant on-treatment and off-treatment increases in mean eGFR relative to placebo (between-group differences of 7.7 +/- 2.1 [p=0.0005] at Week 100 and 4.3 +/- 1.9 mL/min/1.73 m² [p=0.023] at Week 104, respectively), Bard improved PGIC scores relative to placebo (lower values) after 48 and 100 weeks. Categorical summaries also showed more patients randomized to bardoxolone (34%) reported their condition had improved compared to those on placebo (19%) after 100 weeks of treatment.
Conclusion(s): In CARDINAL, Bard significantly preserved eGFR in patients with Alport syndrome and also resulted in improvements in how patients evaluated their wellbeing. (Figure Presented)