Faculty Bibliography
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P2Y12 inhibitor monotherapy versus aspirin monotherapy after short-term dual antiplatelet therapy for percutaneous coronary intervention: Insights from a network meta-analysis of randomized trials
BACKGROUND:inhibitor after a short course of DAPT is actively debated. METHODS:inhibitor monotherapy (P2Y12i group) after short-term DAPT. RESULTS:Our search identified 17 eligible trials enrolling a total of 54,625 patients comparing different DAPT duration. Either of the 2 monotherapy groups did not increase the risk of ischemic outcomes when compared with the long-term DAPT group, without difference between the Aspirin versus the P2Y12i groups. However, both monotherapy groups significantly reduced bleeding when compared with long-term DAPT (Aspirin group: hazard ratio [95% CI]: 0.62 [0.45-0.86], P=.004 and P2Y12i group: 0.68 [0.50-0.93], P=.015). There was no difference in bleeding between the Aspirin versus P2Y12i groups (hazard ratio=0.91 [0.58-1.43], P=.70). CONCLUSIONS:Among patients undergoing PCI, short-term DAPT with continuation of either aspirin or P2Y12i reduced bleeding without increasing ischemic outcomes when compared with long-term DAPT. The choice of antiplatelet therapy after short-term DAPT should be evaluated in well-powered trials.
PMID: 32693196
ISSN: 1097-6744
CID: 4532232
Percutaneous coronary intervention or coronary artery bypass graft surgery for left main coronary artery disease: A meta-analysis of randomized trials [Letter]
We aimed to investigate long-term (≥5 years) outcomes of percutaneous coronary intervention (PCI) versus coronary artery bypass grafting (CABG) for left main coronary artery disease (LMCAD) using a meta-analysis from updated published randomized trials. Our data showed that the risk of all-cause death as well as cardiovascular death, myocardial infarction, and stroke was similar between PCI and CABG, whereas PCI had significantly higher rates of repeat revascularization compared to CABG. Decisions for PCI versus CABG for LMCAD should be based on weighing the upfront morbidity and mortality risk of CABG with late risk of repeat revascularization with PCI and taking into consideration patient preference.
PMID: 32640370
ISSN: 1097-6744
CID: 4517162
Procedural Volume and Outcomes After Primary Percutaneous Coronary Intervention for ST-Segment-Elevation Myocardial Infarction in Kerala, India: Report of the Cardiological Society of India-Kerala Primary Percutaneous Coronary Intervention Registry
Background There are limited data to inform policy mandating primary percutaneous coronary intervention (PPCI) volume benchmarks for catheterization laboratories in low- and middle-income countries. Methods and Results This prospective state-wide registry included ST-segment-elevation myocardial infarction patients with symptoms of <12 hours, or with ongoing ischemia at 12 to 24 hours, reperfused with PPCI. From June 2013 to March 2016, we recruited 5560 consecutive patients. We categorized hospitals on the basis of annual PPCI volumes into low, medium, and high volume (<100, 100-199, and ≥200 PPCIs per year, respectively). Kaplan-Meier curves and Cox regression models were used to examine the association between PPCI volume and 1-year mortality. Among 42 recruiting hospitals, there were 24 (57.2%) low-volume, 8 (19%) medium-volume, and 10 (23.8%) high-volume hospitals. The median (25th-75th percentile) TIMI (Thrombolysis in Myocardial Infarction) ST-segment-elevation myocardial infarction risk score was 3 (2-5). Cardiac arrest before admission occurred in 4.2%, 2.1%, and 2.9% of cases at low-, medium-, and high-volume hospitals, respectively (P=0.02). Total ischemic time differed significantly among low-volume (median [25th-75th percentile], 3.5 [2.4-5.5] hours), medium-volume (median, 3.8 [25th-75th percentile, 2.58-6.05] hours), and high-volume hospitals (median, 4.16 [25th-75th percentile 2.8-6.3] hours) (P=0.01). Vascular access was radial in 61.5%, 71.3%, and 63.2% of cases at low-, medium-, and high-volume hospitals, respectively (P=0.01). The observed 1-year mortality rate was 6.5%, 3.4%, and 8.6% at low-, medium- and high-volume hospitals, respectively (P<0.01), and the difference did not attenuate after multivariate adjustment (low versus medium: hazard ratio [95% CI], 1.80 [1.12-2.90]; high versus medium: hazard ratio [95% CI], 2.53 [1.78-3.58]) (P<0.01). Conclusions Low- and middle-income countries, like India, may have a nonlinear relationship between institutional PPCI volume and outcomes, partly driven by procedural variations and inequalities in access to care.
PMID: 32476563
ISSN: 2047-9980
CID: 4468562
Coronary revascularization and circulatory support strategies in patients with myocardial infarction, multi-vessel coronary artery disease, and cardiogenic shock: Insights from an international survey [Letter]
Cardiogenic shock (CS) complicating acute myocardial infarction (MI) is associated with high mortality. In the absence of data to support coronary revascularization beyond the infarct artery and selection of circulatory support devices or medications, clinical practice may vary substantially.
PMID: 32474205
ISSN: 1097-6744
CID: 4465912
The muddy waters of the J-curve and coronary revascularization
PMID: 32118261
ISSN: 1522-9645
CID: 4336242
Cardiovascular Risk Factors: It's Time to Focus on Variability!
Atherosclerotic heart disease remains a leading cause of morbidity and mortality worldwide. While extensive research supports cardiovascular risk factor reduction in the form of achieving evidence-based blood pressure, lipid, glucose, and body weight targets as a means to improve cardiovascular outcomes, residual risk remains. Emerging data have demonstrated that the intraindividual variability of these risk factor targets potentially contribute to this residual risk. It may therefore be time to define risk factor by not only its magnitude and duration as done traditionally, but perhaps also by the variability of that particular risk factor over time.
PMCID:7379092
PMID: 32821735
ISSN: 2287-2892
CID: 4567362
Differential radiation exposure to interventional cardiologists in the contemporary era [Meeting Abstract]
Background: Exposure to low-dose ionizing radiation is associated with malignancies. Lead garment specifications in the cardiac catheterization laboratory are not currently regulated, potentially resulting in unprotected areas.
Method(s): Interventional cardiology attendings and fellows wore 7 dosimeters, one externally on the thyroid shield and six inside the lead apron: bilateral axilla, chest wall, and pelvis. Radiation protection included a lower table-mounted lead drape, upper ceiling-mounted lead shield, and use of 7.5 frames per second during fluoroscopy. All procedures were performed with operators standing to the right of the patient. The primary endpoint was operator radiation exposure to the left versus right axilla. Radiation exposures in millirem (mrem) per participant over the study period are shown as median [interquartile range] and compared between left- and right-sided measures using paired Wilcoxon tests.
Result(s): Nine participants (66% female) wore dosimeters during 231 cases. Transradial coronary angiography was selected in 81.1% of cases and PCI was performed in 32.1%. A sterile radiation drape placed on the patient abdomen was used in 18.6% of cases. Median dose area product and fluoroscopy time for the participants ranged from 29.0-60.5 Gy cm2 and 6.2-13.5 minutes, respectively. Radiation exposure at the left axilla was higher than the right axilla (5 vs. 0.9 mrem, p=0.018) but did not differ between left or right chest wall and left or right pelvis (Figure).
Conclusion(s): This analysis demonstrates insufficient protection in the left axillary area. The use of additional left axillary protection should be evaluated. (Figure Presented)
Method(s): Interventional cardiology attendings and fellows wore 7 dosimeters, one externally on the thyroid shield and six inside the lead apron: bilateral axilla, chest wall, and pelvis. Radiation protection included a lower table-mounted lead drape, upper ceiling-mounted lead shield, and use of 7.5 frames per second during fluoroscopy. All procedures were performed with operators standing to the right of the patient. The primary endpoint was operator radiation exposure to the left versus right axilla. Radiation exposures in millirem (mrem) per participant over the study period are shown as median [interquartile range] and compared between left- and right-sided measures using paired Wilcoxon tests.
Result(s): Nine participants (66% female) wore dosimeters during 231 cases. Transradial coronary angiography was selected in 81.1% of cases and PCI was performed in 32.1%. A sterile radiation drape placed on the patient abdomen was used in 18.6% of cases. Median dose area product and fluoroscopy time for the participants ranged from 29.0-60.5 Gy cm2 and 6.2-13.5 minutes, respectively. Radiation exposure at the left axilla was higher than the right axilla (5 vs. 0.9 mrem, p=0.018) but did not differ between left or right chest wall and left or right pelvis (Figure).
Conclusion(s): This analysis demonstrates insufficient protection in the left axillary area. The use of additional left axillary protection should be evaluated. (Figure Presented)
EMBASE:632520456
ISSN: 1522-726x
CID: 4558522
Why Fibrinolytic Therapy for STEMI in The COVID-19 Pandemic is Not Your New Best Friend
The COVID-19 pandemic has strained global health care systems in ways that simply could not have been imagined just several months ago. Writing from the heart of New York City - the unfortunate new epicenter of this pandemic - we have been confronted with this new reality head-on. As directors of two major academic cardiac catheterization laboratories in the city, we both have had to operationalize logistical planning of physician and staff redeployments as well as modification of our respective hospital units including conversion of large portions of the catheterization laboratory into COVID-19 intensive care units in order to deal with the surge of COVID-19 patients within the hospital.
PMID: 32339025
ISSN: 1941-7705
CID: 4411892
Health Status after Invasive or Conservative Care in Coronary and Advanced Kidney Disease
BACKGROUND:or receipt of dialysis). A secondary objective of the trial was to assess angina-related health status. METHODS:We assessed health status with the Seattle Angina Questionnaire (SAQ) before randomization and at 1.5, 3, and 6 months and every 6 months thereafter. The primary outcome of this analysis was the SAQ Summary score (ranging from 0 to 100, with higher scores indicating less frequent angina and better function and quality of life). Mixed-effects cumulative probability models within a Bayesian framework were used to estimate the treatment effect with the invasive strategy. RESULTS:Health status was assessed in 705 of 777 participants. Nearly half the participants (49%) had had no angina during the month before randomization. At 3 months, the estimated mean difference between the invasive-strategy group and the conservative-strategy group in the SAQ Summary score was 2.1 points (95% credible interval, -0.4 to 4.6), a result that favored the invasive strategy. The mean difference in score at 3 months was largest among participants with daily or weekly angina at baseline (10.1 points; 95% credible interval, 0.0 to 19.9), smaller among those with monthly angina at baseline (2.2 points; 95% credible interval, -2.0 to 6.2), and nearly absent among those without angina at baseline (0.6 points; 95% credible interval, -1.9 to 3.3). By 6 months, the between-group difference in the overall trial population was attenuated (0.5 points; 95% credible interval, -2.2 to 3.4). CONCLUSIONS:Participants with stable ischemic heart disease, moderate or severe ischemia, and advanced chronic kidney disease did not have substantial or sustained benefits with regard to angina-related health status with an initially invasive strategy as compared with a conservative strategy. (Funded by the National Heart, Lung, and Blood Institute; ISCHEMIA-CKD ClinicalTrials.gov number, NCT01985360.).
PMID: 32227754
ISSN: 1533-4406
CID: 4370052
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
