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Safety and clinical effectiveness of drug-eluting stents for saphenous vein graft intervention in older individuals: Results from the medicare-linked National Cardiovascular Data Registry(®) CathPCI Registry(®) (2005-2009)
Brennan, J Matthew; Sketch, Michael H; Dai, David; Trilesskaya, Marina; Al-Hejily, Wesam; Rao, Sunil V; Brilakis, Emmanouil; Messenger, John C; Shaw, Richard E; Anstrom, Kevin J; Peterson, Eric D; Douglas, Pamela S
OBJECTIVES/OBJECTIVE:To evaluate the safety of drug-eluting stents (DES) when treating patients with failing saphenous vein grafts (SVG). BACKGROUND:DES reduce target vessel revascularization in patients with failing SVGs; however, compared with bare metal stents (BMS), DES have been variably associated with increased mortality. METHODS:Clinical records from National Cardiovascular Data Registry(®) CathPCI Registry(®) (49,325 older individuals [≥65 years] who underwent SVG stenting 2005-2009) were linked to Medicare claims to create a longitudinal record. Death, myocardial infarction (MI), and urgent revascularization with DES versus BMS were evaluated to 3 years using propensity matching (PM). Results were stratified by clinical presentation (acute coronary syndrome [ACS], non-ACS), previous lesion treatment (in-stent, de novo), and graft segment (aortic, body, distal anastomosis). RESULTS:In this older cohort (median age, 75 years), acute presentations were prevalent (ACS, 69%; TIMI flow <3, 45%), and adverse clinical outcomes were common by 3 years (death, 24.5%; MI, 14.6%; urgent revascularization, 29.5%). Among DES patients (n = 31,403), 3-year mortality was lower (vs. BMS) (22.7% vs. 28.0%, P < 0.001; PM hazard ratio [HR] 0.87, 95% confidence interval 0.83-0.91), and no difference was observed in the adjusted risk for MI (PM HR 0.97, 0.91 to 1.03) or urgent revascularization (PM HR 1.04, 0.99-1.08). These findings were independent of clinical presentation, previous lesion treatment, and graft segment (P interaction, ns). CONCLUSIONS:In this large SVG PCI cohort, all-cause mortality was lower among those receiving DES, and no difference in MI or urgent revascularization was observed to 3 years. © 2015 Wiley Periodicals, Inc.
PMID: 26153480
ISSN: 1522-726x
CID: 5224402
An updated comprehensive meta-analysis of bivalirudin vs heparin use in primary percutaneous coronary intervention
Shah, Rahman; Rogers, Kelly C; Matin, Khalid; Askari, Raza; Rao, Sunil V
BACKGROUND:Despite several randomized controlled trials and meta-analyses, the ideal anticoagulant for patients undergoing primary percutaneous coronary intervention (PCI) remains controversial. We performed an updated meta-analysis including recently reported randomized clinical trials that compare bivalirudin and heparin with or without provisional administration of a glycoprotein IIb/IIIa inhibitor (GPI) for primary PCI. METHODS AND RESULTS/RESULTS:Scientific databases and Web sites were searched for randomized clinical trials. Data from 6 trials involving 14,095 patients were included. The pooled risk ratios (RRs) were calculated using random-effects models. Moderator analyses examined the impact of routine use of GPI, radial access, and P2Y12 inhibitors on safety outcomes. At 30 days, patients receiving bivalirudin had rates of major adverse cardiac events similar to those receiving heparin with or without provisional GPI (RR 1.02, 95% CI 0.87-1.19, P = .800), myocardial infarction (RR 1.41, 95% CI 0.94-2.11, P = .089), target vessel revascularization (RR 1.37, 95% CI 0.91-2.04, P = .122), and net adverse clinical events (RR 0.81, 95% CI 0.64-1.01, P = .069). However, bivalirudin use decreased the risk of all-cause mortality (RR 0.81, 95% CI 0.67-0.99, P = .041) and cardiac mortality (RR 0.68, 95% CI 0.51-0.91, P = .009) at 30 days, There were higher rates of acute stent thrombosis (RR 3.31, 95% CI 1.79-6.10, P < .001) in patients receiving bivalirudin. Bivalirudin use also decreased the risk of major bleeding at 30 days by 37% (RR 0.63, 95% CI 0.44-0.90, P = .012), but bleeding risk varied depending on routine GPI use with heparin (RR 0.44, 95% CI 0.23-0.81, P = .009) vs bailout (RR 0.73, 95% CI 0.42-1.25, P = .252), predominantly radial access (RR 0.54, 95% CI 0.25-1.15, P = .114) vs non-radial access (RR 0.60, 95% CI 0.36-0.99, P = .049), and second-generation P2Y12 inhibitor use with bivalirudin (RR 0.70, 95% CI 0.40-1.24, P = .226) vs clopidogrel use (RR 0.39, 95% CI 0.18-0.85, P = .018). CONCLUSIONS:In primary PCI, relative to heparin, bivalirudin reduces the risk for all-cause mortality, cardiac mortality, and major bleeding but yields similar rates of major adverse cardiac event and net adverse clinical event at 30 days. However, the benefit of a reduction in bleeding with bivalirudin appears to be modulated by the concurrent administration of second-generation P2Y12 inhibitors with bivalirudin, using radial access, and avoiding routine GPI use with heparin.
PMID: 26699596
ISSN: 1097-6744
CID: 5224552
A Call for Comprehensive Forearm Access? [Comment]
Sawlani, Neal; Rao, Sunil V; Bhatt, Deepak L
PMID: 26716588
ISSN: 1557-2501
CID: 5224562
Post-procedural/pre-hemostasis intra-arterial nitroglycerin after transradial catheterization: A gender based analysis
Dharma, Surya; Kedev, Sasko; Patel, Tejas; Sukmawan, Renan; Gilchrist, Ian C; Rao, Sunil V
BACKGROUND:We analyzed the effect of nitroglycerin on radial artery occlusion (RAO) in women undergoing transradial catheterization. METHODS:A total of 1706 patients undergoing transradial catheterization were randomized to receive either 500μg intra-arterial nitroglycerin or placebo at the end of the radial procedure. We explored the gender-based analysis between women (n=539) and men (n=1167). The primary outcome was the incidence of RAO as confirmed by absence of antegrade flow at one day after the transradial procedure evaluated by duplex ultrasound of the radial artery. RESULTS:The use of nitroglycerin, as compared with placebo, did not significantly reduce the risk of RAO in women patients [odds ratio, 0.69; 95% confidence interval (CI), 0.38 to 1.26; P=0.147]. The risk of RAO was higher in women age <60years as compared with women age ≥60years [5.6% vs. 3.5%; odds ratio, 2.16; 95% CI, 1.18 to 3.94; P=0.008]. In women age <60years (n=237), both counter puncture technique and a duration of hemostasis ≥4h were associated with a similar enhanced risk of developing RAO (odds ratio, 3.51; 95% CI, 1.59 to 7.72; P<0.001). CONCLUSIONS:The administration of nitroglycerin at the end of a transradial catheterization in women did not reduce the risk of RAO as determined by ultrasound one day after the radial procedure. Age <60years was associated with a higher risk of RAO compared with age ≥60years in women. Further strategies to reduce RAO in women are needed.
PMID: 26797427
ISSN: 1878-0938
CID: 5224582
Meta-Analysis of Effects of Bivalirudin Versus Heparin on Myocardial Ischemic and Bleeding Outcomes After Percutaneous Coronary Intervention
Perez, Alberto E. Barria; Rao, Sunil V.; Jolly, Sanjit J.; Pancholy, Samir B.; Plourde, Guillaume; Rimac, Goran; Poirier, Yann; Costerousse, Olivier; Bertrand, Olivier F.
ISI:000373968500010
ISSN: 0002-9149
CID: 5226512
Initial Report From an Emergency-Department-Based Registry of NSTEMI Patients Given Upstream Advanced Oral Antiplatelet Therapy [Meeting Abstract]
Pollack, Charles V.; Bhandary, Durgesh D.; Frost, Alex; Peacock, W. Frank; Diercks, Deborah B.; Silber, Steven H.; Rao, Sunil V.; Bangalore, Sripal; Reicher, Barry; Burke, Lea M.; DeRita, Renato; Khan, Naeem D.
ISI:000396815301071
ISSN: 0009-7322
CID: 5226592
Patterns of Use and Outcomes of Antithrombotic Therapy in End Stage Renal Disease Patients Undergoing PCI: Observations From NCDR [Meeting Abstract]
Washam, Jeffrey B.; Mccoy, Lisa A.; Wojdyla, Daniel M.; Patel, Manesh R.; Klein, Andrew J.; Abbott, J. D.; Rao, Sunil V.
ISI:000396815604090
ISSN: 0009-7322
CID: 5226612
Sex-related differences in outcomes after percutaneous coronary intervention (PCI) in patients with diabetes presenting with acute coronary syndrome (ACS): Results from the PROMETHEUS study [Meeting Abstract]
Vogel, Birgit; Baber, Usman; Sartori, Samantha; Chandrasekhar, Jaya; Aquino, Melissa; Farhan, Serdar; Kini, Annapoorna; Weintraub, William; Rao, Sunil; Kapadia, Samir; Weiss, Sandra; Strauss, Craig; Toma, Catalin; Muhlestein, J. Brent; DeFranco, Anthony; Effron, Mark; Keller, Stuart; Baker, Brian; Pocock, Stuart; Henry, Timothy; Mehran, Roxana
ISI:000397332900268
ISSN: 0735-1097
CID: 5488532
The Multidimensionality of Cardiovascular Procedures [Comment]
Rao, Sunil V
PMID: 26477636
ISSN: 1558-3597
CID: 5224462
Proficiency With Vascular Access: Don't Rob Peter to Pay Paul [Editorial]
Rao, Sunil V; Nolan, Jim
PMID: 26604057
ISSN: 1876-7605
CID: 5224502