Faculty Bibliography

BACKGROUND:This study evaluates the prognostic utility of the RV/LV diameter ratio in predicting low cardiac index (CI) in patients with acute intermediate-risk PE. METHODS:We conducted a retrospective analysis of 112 patients with acute PE who underwent catheter-based therapies. The RV/LV diameter ratio was measured from standard axial views on computed tomography pulmonary angiogram (CTPA). Multivariable regression models were used to assess the relationship between the RV/LV diameter ratio and invasive hemodynamic parameters. RESULTS:lower cardiac index (p = 0.002). The RV/LV ratio demonstrated moderate sensitivity (64.5 %) and high specificity (84.2 %) for predicting low cardiac index. CONCLUSION/CONCLUSIONS:The RV/LV diameter ratio offers real-time risk stratification and is a predictor of low cardiac index in patients with acute PE.

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.

BACKGROUND:Randomized trials of chronic total occlusion (CTO) revascularization vs medical therapy have yielded inconsistent results. OBJECTIVES/OBJECTIVE:The aim of this study was to evaluate outcomes with an initial invasive strategy (INV) vs an initial conservative strategy (CON) in patients with coronary computed tomographic angiography (CCTA)-determined CTO in the ISCHEMIA (International Study of Comparative Health Effectiveness With Medical and Invasive Approaches) trial. METHODS:Participants in ISCHEMIA who underwent CCTA evaluated for CTO by the core laboratory (3,113 of 5,179 randomized patients [60%]) were categorized into subgroups with (100% stenosis) and without (<100% stenosis) CTO. Primary analysis compared outcomes in those randomized to INV vs CON using an intention-to-treat approach. Secondary analyses compared outcomes using inverse probability weighting to model successful CTO revascularization (REV) in all INV participants vs CON participants. RESULTS:Of the 3,113 CCTA-evaluable participants, 1,470 had at least 1 CTO (752 INV and 718 CON). INV did not reduce cardiovascular (CV) death or myocardial infarction (MI) (5-year difference -3.5%; 95% CI: -7.8% to 0.8%) and resulted in more procedural MIs (2.5%; 95% CI: 1.0%-4.0%) but fewer spontaneous MIs (-6.3%; 95% CI: -9.7% to -3.2%) than CON. CTO REV modeled across INV had a high probability (>90%) of any lower CV death or MI, MI, spontaneous MI, unstable angina, and heart failure counterbalanced by a higher rate of procedural MI. CTO REV significantly improved angina-related quality of life (mean difference 4.6 points), Rose Dyspnea Scale score (rescaled) (mean difference 5.3 points), and EQ-5D visual analog scale score (4.6 points). CONCLUSIONS:In the ISCHEMIA trial, the risks and benefits of INV compared with CON were similar among patients with and without CCTA-determined CTO (more frequent procedural MI, less frequent spontaneous MI, and significantly improved angina and dyspnea-related quality of life). In an observational comparison, successful CTO REV was associated with a high probability of lower CV death or MI (driven by lower MI) compared with CON. (International Study of Comparative Health Effectiveness With Medical and Invasive Approaches [ISCHEMIA]; NCT01471522).

BACKGROUND:Guideline-directed medical therapy (GDMT) with multiple risk factor goals is recommended for patients with chronic coronary disease (CCD), yet achieving all GDMT goals is uncommon. The relative importance of these goals and timing of their attainment on cardiovascular events is uncertain. OBJECTIVES/OBJECTIVE:This study aims to describe the relationship between achieving specific GDMT goals, when they are achieved, and clinical outcomes. METHODS:This was an observational study of participants with CCD in the ISCHEMIA (International Study of Comparative Health Effectiveness with Medical and Invasive Approaches) trial. The primary outcome was cardiovascular (CV) death or myocardial infarction (MI). GDMT goals were systolic blood pressure (SBP) <130 mm Hg, low-density lipoprotein cholesterol <70 mg/dL, not smoking, and antiplatelet therapy. Frequency of GDMT goals met at baseline and during follow-up is described. Bayesian joint modeling for longitudinal goal status and time-to-event analyses characterized the relative importance of specific GDMT goal attainment and timing with CV death/MI. RESULTS:All 5,179 ISCHEMIA participants were included. Among 4,914 participants with complete data on all 4 GDMT goals at baseline, 386 (9%), 2,073 (42%), 1,843 (38%), and 612 (12%) met 0-1, 2, 3, and 4 GDMT goals, respectively. The 4-year cumulative event rate for CV death/MI was highest for participants who attained no GDMT goals (24.5%; 95% credible interval [CrI]: 13.5%-42.2%) and lowest for those who attained all goals at baseline and remained at goal during follow-up (8.7%; 95% CrI: 6.7%-10.9%). SBP goal attainment was associated with a significant absolute event reduction in CV death/MI (-5.1%; 95% CrI: -11.3% to -1.0%), followed by antiplatelet therapy (-11.2%; 95% CrI: -29.1% to 0.8%), achieving low-density lipoprotein cholesterol <70 mg/dL (-2.0%; 95% CrI: -6.0% to 2.4%), and not smoking (-1.7%; 95% CrI: -9.3% to 4.2%). Ten millimeters of mercury lower SBP during follow-up was associated with 10% relative risk reduction of CV death/MI (RR [relative risk] = 0.90; 95% CrI: 0.82-0.98), after adjusting for other GDMT goals and baseline characteristics. CONCLUSIONS:Among participants with CCD, early attainment and maintenance of GDMT goals, especially SBP, were associated with fewer cardiovascular events. Compared with no GDMT goals at target, having all 4 GDMT goals at target at baseline was associated with an absolute 16% fewer CV deaths and MIs. (ISCHEMIA [International Study of Comparative Health Effectiveness With Medical and Invasive Approaches]; NCT01471522).

The role of revascularization and percutaneous coronary intervention (PCI) in patients with acute coronary syndrome is well established. However, the incremental value of revascularization over guideline-directed medical therapy is controversial. Currently available data supports the use of PCI to improve angina and quality of life for chronic coronary disease and heart failure (HF). However, there is insufficient data to support revascularization with PCI to improve mortality, reduce cardiovascular events, or improve ejection fraction over medical therapy alone. Additional trials are necessary to identify HF patients who may benefit from revascularization, and the optimal revascularization strategy for this population.