Faculty Bibliography
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Management of Coronary Disease in Patients with Advanced Kidney Disease
BACKGROUND:Clinical trials that have assessed the effect of revascularization in patients with stable coronary disease have routinely excluded those with advanced chronic kidney disease. METHODS:We randomly assigned 777 patients with advanced kidney disease and moderate or severe ischemia on stress testing to be treated with an initial invasive strategy consisting of coronary angiography and revascularization (if appropriate) added to medical therapy or an initial conservative strategy consisting of medical therapy alone and angiography reserved for those in whom medical therapy had failed. The primary outcome was a composite of death or nonfatal myocardial infarction. A key secondary outcome was a composite of death, nonfatal myocardial infarction, or hospitalization for unstable angina, heart failure, or resuscitated cardiac arrest. RESULTS:At a median follow-up of 2.2 years, a primary outcome event had occurred in 123 patients in the invasive-strategy group and in 129 patients in the conservative-strategy group (estimated 3-year event rate, 36.4% vs. 36.7%; adjusted hazard ratio, 1.01; 95% confidence interval [CI], 0.79 to 1.29; P = 0.95). Results for the key secondary outcome were similar (38.5% vs. 39.7%; hazard ratio, 1.01; 95% CI, 0.79 to 1.29). The invasive strategy was associated with a higher incidence of stroke than the conservative strategy (hazard ratio, 3.76; 95% CI, 1.52 to 9.32; P = 0.004) and with a higher incidence of death or initiation of dialysis (hazard ratio, 1.48; 95% CI, 1.04 to 2.11; P = 0.03). CONCLUSIONS:Among patients with stable coronary disease, advanced chronic kidney disease, and moderate or severe ischemia, we did not find evidence that an initial invasive strategy, as compared with an initial conservative strategy, reduced the risk of death or nonfatal myocardial infarction. (Funded by the National Heart, Lung, and Blood Institute and others; ISCHEMIA-CKD ClinicalTrials.gov number, NCT01985360.).
PMID: 32227756
ISSN: 1533-4406
CID: 5451232
Coronary OCT and Cardiac MRI to Determine Underlying Causes of Minoca in Women [Meeting Abstract]
ISI:000639226400050
ISSN: 0009-7322
CID: 5285732
Saddle pulmonary embolism and clot in transit in COVID-19 infection: a case report of catastrophic venous thromboembolism
Background /UNASSIGNED:Coronavirus disease 2019 (COVID-19) is associated with a coagulopathy favouring thrombosis over bleeding that imparts a poor prognosis. Clot in transit (CIT) is considered a rare entity and the most severe form of venous thromboembolism (VTE), carrying a higher mortality than isolated pulmonary embolism (PE). The incidence of this phenomenon in patients with COVID-19 infection is unknown and likely under-recognized. Case summary /UNASSIGNED:During the peak of the COVID-19 pandemic in New York City, a 70-year-old Hispanic female presented with syncope due to a saddle PE further complicated by a highly mobile CIT. Polymerase chain reaction was positive for COVID-19 infection, however, there was no evidence of lung parenchymal involvement or hyper-inflammation. Based on consensus from a multidisciplinary team, aspiration thrombectomy was attempted to treat this extreme case of VTE, however, the patient died during the procedure. Discussion /UNASSIGNED:This case raises awareness to the most catastrophic form of VTE, presenting in an early phase of COVID-19 infection without the typical hyper-inflammation and severe lung injury associated with development of COVID-related coagulopathy. It also serves to inform on the critical role echocardiography has in the comprehensive evaluation and re-evaluation of hospitalized patients with COVID-19, and the importance of a multidisciplinary organized approach in clinical decision-making for this complex and poorly understood disease and its sequelae.
PMCID:7891250
PMID: 33628997
ISSN: 2514-2119
CID: 4794812
Optimal medical therapy attainment by dialysis status in the ischemia-CKD trial [Meeting Abstract]
Background: The efficacy of an aggressive multiple risk factor intervention approach - optimal medical therapy (OMT) - to reduce major adverse cardiovascular events in patients with CKD has not been tested.
Objective(s): to examine OMT goal attainment in patients with CKD on dialysis (CKD-D) and non-dialysis CKD (CKD-ND) in the ISCHEMIA-CKD trial.
Method(s): OMT was recommended to all participants in ISCHEMIA-CKD. Longitudinal trajectories of individual OMT components (smoking cessation, systolic blood pressure (SBP) <140 mmHg, low density lipoprotein (LDL) cholesterol <70 mg/dL, high-intensity statin use, and aspirin use) were modeled over study follow-up. Covariateadjusted percentage point difference in each OMT goal achieved at 24 months between CKD-D and CKD-ND groups (% difference [95% credible interval (CrI)]) was estimated.
Result(s): There were 415 CKD-D and 362 CKD-ND patients at baseline. CKD-D were younger (61 v 67 yrs, p<0.001) and less often diabetic (53% v 62%, p=0.023). CKD-D patients were 7.9 % (0.7%, 14.8%) more likely than CKD-ND to attain the SBP goal at 24 months (Figure). CKD-D patients were 22.7% (-33.3%, -11.4%) less likely to receive high-intensity statins. There was a steady and similar increase in proportional achievement of OMT during follow up.
Conclusion(s): OMT improved over time in advanced CKD-ND and CKD-D. CKD-D achieved the SBP goal more than CKD-ND, yet CKD-D were less likely to be treated with high-intensity statin. Future studies should explore systemic and patient-related barriers to attainment of OMT in this high-risk cohort.(Figure Presented)
Objective(s): to examine OMT goal attainment in patients with CKD on dialysis (CKD-D) and non-dialysis CKD (CKD-ND) in the ISCHEMIA-CKD trial.
Method(s): OMT was recommended to all participants in ISCHEMIA-CKD. Longitudinal trajectories of individual OMT components (smoking cessation, systolic blood pressure (SBP) <140 mmHg, low density lipoprotein (LDL) cholesterol <70 mg/dL, high-intensity statin use, and aspirin use) were modeled over study follow-up. Covariateadjusted percentage point difference in each OMT goal achieved at 24 months between CKD-D and CKD-ND groups (% difference [95% credible interval (CrI)]) was estimated.
Result(s): There were 415 CKD-D and 362 CKD-ND patients at baseline. CKD-D were younger (61 v 67 yrs, p<0.001) and less often diabetic (53% v 62%, p=0.023). CKD-D patients were 7.9 % (0.7%, 14.8%) more likely than CKD-ND to attain the SBP goal at 24 months (Figure). CKD-D patients were 22.7% (-33.3%, -11.4%) less likely to receive high-intensity statins. There was a steady and similar increase in proportional achievement of OMT during follow up.
Conclusion(s): OMT improved over time in advanced CKD-ND and CKD-D. CKD-D achieved the SBP goal more than CKD-ND, yet CKD-D were less likely to be treated with high-intensity statin. Future studies should explore systemic and patient-related barriers to attainment of OMT in this high-risk cohort.(Figure Presented)
EMBASE:633700665
ISSN: 1533-3450
CID: 4750072
Ambulatory Blood Pressure Monitoring to Predict Response to Renal Denervation: A Post Hoc Analysis of the RADIANCE-HTN SOLO Study
Renal denervation (RDN) is effective in lowering blood pressure (BP) in patients with hypertension. The issue remains how to best identify potential responders. Ambulatory BP monitoring may be useful. Baseline nighttime systolic BP (SBP) ≥136 mm Hg and its variability (SD) ≥12 mm Hg in DENER-HTN trial or 24-hour heart rate ≥73.5 bpm in SPYRAL HTN-OFF MED Trial were shown to predict the BP response to RDN. We applied these criteria to the patients with hypertension in the sham-controlled RADIANCE-HTN SOLO trial to predict the BP response to ultrasound RDN at 2 months while patients were maintained off medications. BP responders were defined as: clinical with 24-hour SBP <130 mm Hg (RDN: 22/64 versus sham: 7/58); meaningful with 24-hour SBP reduction ≥10 mm Hg (RDN: 24/64, sham: 7/58); and extreme with 24-hour SBP reduction above mean+2 SD of the SBP decrease in the sham group, that is, ≥16.5 mm Hg (RDN: 10/64 versus sham: 2/58). The predictive criteria reported above were tested for sensitivity, specificity, and positive and negative predictive values. The predictive value varied according to the definition of response, with the clinical definition being strongly influenced by regression to the mean. Baseline nighttime SBP and its variability, especially when combined, offered good specificity (>90% irrespective of definition) but low sensitivity (from 9.1% to 30% depending on the definition) to predict responders; the heart rate criterion had insufficient predictive value. This analysis suggests the potential role of nighttime SBP and its variability to predict BP response to RDN in patients with hypertension. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT02649426.
PMID: 33356403
ISSN: 1524-4563
CID: 4731142
Choosing between aspirin or P2Y12 monotherapy after short course of DAPT [Letter]
PMID: 33248474
ISSN: 1097-6744
CID: 4693692
Meta-analysis of PCI vs. CABG for left main disease revisited [Letter]
PMID: 33187625
ISSN: 1097-6744
CID: 4672132
TCT CONNECT-271 The MeRes-1 Extend Trial: 2-Year Clinical and 6-Month Imaging Outcomes of Thin-Strut Sirolimus-Eluting BRS in Patients With De Novo Coronary Artery Lesions [Meeting Abstract]
Background: The long- term clinical outcomes of percutaneous coronary intervention can be improved by replacing metallic drug-eluting stents with bioresorbable vascular scaffolds. The MeRes-1 Extend trial was designed to assess the safety and efficacy of a novel thin-strut MeRes100 bioresorbable vascular scaffold (Meril Life Sciences) in a diverse patient population.
Method(s): The MeRes-1 Extend was a prospective, multicenter, single-arm study that enrolled 64 patients in Spain, Macedonia, Brazil, South Africa, Malaysia, and Indonesia. Major adverse cardiac events, consisting of cardiac death, myocardial infarction, and ischemia-driven target lesion revascularisation, were the safety endpoint. At baseline and 6-month follow-up, quantitative coronary angiography and optical coherence tomography were performed.
Result(s): Of all patients enrolled (mean age: 58.30 +/- 9.02 years), 76.56% had hypertension, 26.56% had diabetes mellitus, 48.44% had dyslipidemia, and 28.13% had a previous myocardial infarction; 68.75% of patients presented with stable angina, 9.38% with unstable angina, and 21.88% with silent ischemia. A total of 69 target lesions (mean length: 14.37 +/- 5.89 mm) were detected of which 71.01% were type B2/C. Procedural and device success were achieved in 64 and 62 patients, respectively. Major adverse cardiac events rate was reported in 1 patient (1.61%) in the form of ischemia-driven target lesion revascularization; there were no cases of myocardial infarction, cardiac death, or scaffold thrombosis. At 6-month angiographic follow-up (n = 32), mean in-scaffold late lumen loss was 0.18 +/- 0.31 mm. Optical coherence tomography analysis (n = 21) showed 97.95 +/- 3.69% strut coverage and mean scaffold area of 7.56 +/- 1.79 mm2, with no strut malapposition. Updated data will be presented during Transcatheter Cardiovascular Therapeutics 2020 annual meeting.
Conclusion(s): Two-year clinical and 6-month imaging outcomes of MeRes-1 Extend trial demonstrated favorable safety and efficacy of novel thin-strut MeRes100 sirolimus-eluting bioresorbable vascular scaffolds in patients with de novo coronary artery lesions. Categories: CORONARY: Stents: Bioresorbable Vascular Scaffolds
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Method(s): The MeRes-1 Extend was a prospective, multicenter, single-arm study that enrolled 64 patients in Spain, Macedonia, Brazil, South Africa, Malaysia, and Indonesia. Major adverse cardiac events, consisting of cardiac death, myocardial infarction, and ischemia-driven target lesion revascularisation, were the safety endpoint. At baseline and 6-month follow-up, quantitative coronary angiography and optical coherence tomography were performed.
Result(s): Of all patients enrolled (mean age: 58.30 +/- 9.02 years), 76.56% had hypertension, 26.56% had diabetes mellitus, 48.44% had dyslipidemia, and 28.13% had a previous myocardial infarction; 68.75% of patients presented with stable angina, 9.38% with unstable angina, and 21.88% with silent ischemia. A total of 69 target lesions (mean length: 14.37 +/- 5.89 mm) were detected of which 71.01% were type B2/C. Procedural and device success were achieved in 64 and 62 patients, respectively. Major adverse cardiac events rate was reported in 1 patient (1.61%) in the form of ischemia-driven target lesion revascularization; there were no cases of myocardial infarction, cardiac death, or scaffold thrombosis. At 6-month angiographic follow-up (n = 32), mean in-scaffold late lumen loss was 0.18 +/- 0.31 mm. Optical coherence tomography analysis (n = 21) showed 97.95 +/- 3.69% strut coverage and mean scaffold area of 7.56 +/- 1.79 mm2, with no strut malapposition. Updated data will be presented during Transcatheter Cardiovascular Therapeutics 2020 annual meeting.
Conclusion(s): Two-year clinical and 6-month imaging outcomes of MeRes-1 Extend trial demonstrated favorable safety and efficacy of novel thin-strut MeRes100 sirolimus-eluting bioresorbable vascular scaffolds in patients with de novo coronary artery lesions. Categories: CORONARY: Stents: Bioresorbable Vascular Scaffolds
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EMBASE:2008355394
ISSN: 0735-1097
CID: 4654752
TCT CONNECT-248 Optimal Duration of Dual Antiplatelet Therapy After Percutaneous Coronary Intervention in Patients With Acute Coronary Syndrome: Insights From a Network Meta-Analysis of Randomized Trials [Meeting Abstract]
Background: With newer generation drug-eluting stents, the minimal duration of dual antiplatelet therapy (DAPT) recommended by guidelines has been reduced to 6 months in patients with stable coronary artery disease. Whether shorter duration of DAPT is safe in patients presenting with acute coronary syndrome (ACS) remains controversial. The aim of this study was to investigate the optimal DAPT duration (<=3 months vs. 6 months vs. 12 months vs. >12 months) among patients with ACS undergoing PCI.
Method(s): PubMed and Embase were searched through January 2020 for randomized controlled trials of DAPT duration in patients with ACS. The ischemic outcomes were all-cause death, myocardial infarction, and stent thrombosis. The safety outcome was major and/or clinically relevant bleeding.
Result(s): This search identified 14 eligible trials enrolling a total of 31,837 patients comparing different DAPT duration in patients with ACS. Short-term DAPT (<=3 months or 6 months) did not increase ischemic outcomes compared with long-term DAPT (12 months and >12 months). For bleeding outcomes, DAPT duration <=3 months was associated with significant reduction in bleeding compared with DAPT durations of 6 months, 12 months, or >12 months (hazard ratio [HR]: 0.60; 95% confidence interval [CI]: 0.37 to 0.98; HR: 0.68; 95% CI: 0.54 to 0.85; and HR: 0.43; 95% CI: 0.34 to 0.54, respectively).These findings were similar when limited to second-generation drug-eluting stents.
Conclusion(s): Data from this meta-analysis of randomized trials support short-term DAPT (<=3 months and 6 months) even in patients with ACS undergoing PCI. Guidelines should consider short-term DAPT even in patients presenting with ACS, especially in this era of newer generation drug-eluting stents. Categories: CORONARY: Acute Coronary Syndromes
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Method(s): PubMed and Embase were searched through January 2020 for randomized controlled trials of DAPT duration in patients with ACS. The ischemic outcomes were all-cause death, myocardial infarction, and stent thrombosis. The safety outcome was major and/or clinically relevant bleeding.
Result(s): This search identified 14 eligible trials enrolling a total of 31,837 patients comparing different DAPT duration in patients with ACS. Short-term DAPT (<=3 months or 6 months) did not increase ischemic outcomes compared with long-term DAPT (12 months and >12 months). For bleeding outcomes, DAPT duration <=3 months was associated with significant reduction in bleeding compared with DAPT durations of 6 months, 12 months, or >12 months (hazard ratio [HR]: 0.60; 95% confidence interval [CI]: 0.37 to 0.98; HR: 0.68; 95% CI: 0.54 to 0.85; and HR: 0.43; 95% CI: 0.34 to 0.54, respectively).These findings were similar when limited to second-generation drug-eluting stents.
Conclusion(s): Data from this meta-analysis of randomized trials support short-term DAPT (<=3 months and 6 months) even in patients with ACS undergoing PCI. Guidelines should consider short-term DAPT even in patients presenting with ACS, especially in this era of newer generation drug-eluting stents. Categories: CORONARY: Acute Coronary Syndromes
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EMBASE:2008355152
ISSN: 0735-1097
CID: 4654812
Protected Rotational Atherectomy and DK NanoCrush POT rePOT Technique With Dual Guiding Catheters for Unprotected Distal Left Main
PMID: 33069655
ISSN: 1876-7605
CID: 4641862
