The content should be medically relevant and adhere docstop content guidelines . Docstop doesn’t support any brand related promotional activities

Share articles, case studies and web videos

Method : start a topic- select private, add group, give name, add email ids, and send to your selected group

CRITICAL JOURNAL REVIEW

FAME- 2 at 5 YEARS: Five-Year Outcomes with PCI Gui.....

CRITICAL JOURNAL REVIEW

FAME- 2 at 5 YEARS: Five-Year Outcomes with PCI Gui.....


Hybrid Coronary Revascularization in Selected Patients With Multivessel Disease 5-Year.....

Hybrid Coronary Revascularization in Selected Patients With Multivessel Disease 5-Year.....


Deferred vs. performed revascularization for coronary stenosis with grey-zone fraction.....

Deferred vs. performed revascularization for coronary stenosis with grey-zone fraction.....


Reviewed by Dr Akshay Mehta

Key Points:

1. The prognosis for deferred and performed revascularization in coronary stenosis with FFR values in the grey zone (0.75–0.80) was evaluated in 1334 native coronary stenosis in as many number of patients.

2.  The primary outcome, a composite of death, target-vessel myocardial infarction (MI), and target vessel revascularization (TVR) as well as overall  mortality and spontaneous MI did not differ between the groups, whereas myocardial infarction (mainly periprocedural) was significantly higher in the performed group and target vessel revascularization was significantly higher in the deferred group.

Study Protocol:

Out of all patients in The Interventional Cardiology Research In-cooperation Society Fractional Flow Reserve (IRIS-FFR) registry, which is a prospective, multicenter registry designed for investigating the prognosis of coronary stenosis assessed using FFR in routine clinical practice, patients with a de novo native coronary artery stenosis with an FFR value in the grey zone (0.75–0.80) were enrolled for this study. The decision regarding revascularization for such patients was at the operator’s discretion. 

Follow-ups were conducted during hospitalization, at 30 days, 6 months, and 12 months after the index procedure and subsequently at 6 month intervals. The patients’ clinical status, interventions, and adverse events were recorded at each follow up.

Outcomes:

During a median follow-up of 2.9 years, overall mortality did not differ between the groups (2.5% in deferred group vs. 2.0% in performed group; aHR 0.82, 95% CI 0.34–2.00; P = 0.66). The performed group showed a significantly higher risk of target vessel MI (0.7% vs. 3.2%; aHR 0.27, 95% CI 0.09–0.80; P = 0.02), mainly because of a higher risk of periprocedural MI but the incidence of spontaneous MI did not differ between the groups (0.7% vs. 0.5%; aHR 1.85, 95% CI 0.35–9.75; P = 0.47). Definite stent thrombosis did not occur. The risk of TVR was higher in the deferred group (5.9% vs. 3.7%; aHR 2.17, 95% CI 1.17–4.02; P = 0.01).

The clinical outcomes on subgroup analysis and propensity score matching showed a similar trend.

The indications for TVR were angina with CCS III or IV, ischemia documented by non-invasive test or angiographic progression to more than 90% diameter stenosis.

ACS and multivessel disease were the dominant predictors for major adverse cardiac events in both the groups.

Conclusion:

For coronary stenosis with grey-zone FFR values, revascularization was associated with a high risk of periprocedural MI which was offset by a high risk of TVR in the deferred group, without any significant difference in overall clinical outcomes including mortality.

Comment:

Although an observational study, it is based on the largest cohort of prospectively enrolled patients with the longest follow-up duration that could give clinically relevant information for the issue of FFR in the grey zone.

The other strengths were: adjudication by an independent committee, adjustment for potential confounders, and vessel-level outcomes.

Questions that beg for answers are the reasons for revascularizing some lesions as compared to others, information about baseline symptoms, and upstream stress tests.

Like prior several non-randomized, observational studies, the same message appears from this study, namely that death and myocardial infarction remain uncommon in the FFR grey zone. Subsequent TVR takes place in more number of deferred stenoses with a higher incidence of periprocedural MI in the revascularization group.

Suggested Readings:

  1. Tonino PA, De Bruyne B, Pijls NH, Siebert U, Ikeno F, van't Veer M, et al. FAME Study Investigators. Fractional flow reserve versus angiography for guiding percutaneous coronary intervention. N Engl J Med 2009;360:213–224.

 

  1. De Bruyne B, Fearon WF, Pijls NHJ, Barbato E, Tonino P, Piroth Z, et al. FAME 2 Trial Investigators. Fractional flow reserve-guided PCI for stable coronary artery disease. N Engl J Med  2014;371:1208–1217.

 

  1. Zimmermann FM, Ferrara A, Johnson NP, van Nunen LX, Escaned J, Albertsson P, et al. Deferral vs. performance of percutaneous coronary intervention of functionally non-significant coronary stenosis: 15-year follow-up of the DEFER trial. Eur Heart J  2015;36:3182–3188.

 

  1. Courtis J, Rodés-Cabau J, Larose E, Déry J-P, Nguyen CM, Proulx G, et al. Comparison of medical treatment and coronary revascularization in patients with moderate coronary lesions and borderline fractional flow reserve measurements. Catheter Cardiovasc Interv  2008;71:541–548.

 

  1. Lindstaedt M, Halilcavusogullari Y, Yazar A, Holland-Letz T, Bojara W, Mügge A, et al. Clinical outcome following conservative vs revascularization therapy in patients with stable coronary artery disease and borderline fractional flow reserve measurements. Clin Cardiol  2010;33:77–83

 

  1. Adjedj J, De Bruyne B, Flore V, Di Gioia G, Ferrara A, Pellicano M, et al. Significance of intermediate values of fractional flow reserve in patients with coronary artery disease. Circulation 2016;133:502–508.

 

  1. Agarwal SK, Kasula S, Edupuganti MM, Raina S, Shailesh F, Almomani A, et al. Clinical decision-making for the hemodynamic “gray zone” (FFR 0.75-0.80) and long-term outcomes. J Invasive Cardiol  2017;29:371–376.

 

  1. Yamashita J, Tanaka N, Shindo N, Ogawa M, Kimura Y, Sakoda K, et al. Seven-year clinical outcomes of patients with moderate coronary artery stenosis after deferral of revascularization based on gray-zone fractional flow reserve. Cardiovasc Interv Ther 2015;30:209–215.

 

  1. Shiono Y, Kubo T, Tanaka A, Ino Y, Yamaguchi T, Tanimoto T, et al. Long-term outcome after deferral of revascularization in patients with intermediate coronary stenosis and gray-zone fractional flow reserve. Circ J 2014;79:91–95.

 

  1. Petraco R, Sen S, Nijjer S, Echavarria-Pinto M, Escaned J, Francis DP, et al. Fractional flow reserve-guided revascularization: practical implications of a diagnostic gray zone and measurement variability on clinical decisions. JACC Cardiovasc Interv 2013;6:222–225.

11. Johnson NP and  Zimmermann FM. Yellow traffic lights and grey zone fractional flow reserve values: stop or go? European Heart Journal, 2018:39(18):1620–1622.

">

Introduction:

Patients with myocardial infarction (MI) and multi-.....

Introduction:

Patients with myocardial infarction (MI) and multi-.....


Mobile Phone Detection of Atrial Fibrillation with Mechanocardiography The MODE-AF Stu.....

Mobile Phone Detection of Atrial Fibrillation with Mechanocardiography The MODE-AF Stu.....


Heart Failure with Mid-Range Ejection Fraction: A No Man's Land In Search Of Its M.....

Heart Failure with Mid-Range Ejection Fraction: A No Man's Land In Search Of Its M.....


https://onlinelibrary.wiley.com/doi/abs/10.1002/ejhf.1149, cited on April 25, 2018.

Cleland JGF, Bunting KV, Flather MD, Altman DG, Holmes J, Coats AJS, et al. Beta-blockers in Heart Failure Collaborative Group; Beta-blockers for heart failure with reduced, mid-range, and preserved ejection fraction: an individual patient-level analysis of double-blind randomized trials, European Heart Journal, 2018;39(1): 26–35

">

Approximately 35 – 40% patients with STEMI have MV coronary artery disease.  The in.....

Approximately 35 – 40% patients with STEMI have MV coronary artery disease.  The in.....


One year outcomes of patients undergoing primary PTCA for Myocardial- Infarction treat.....

One year outcomes of patients undergoing primary PTCA for Myocardial- Infarction treat.....


Statins in peripheral arterial disease

- Dr .....

Statins in peripheral arterial disease

- Dr .....


- Dr Akshay Mehta

Source: Arya S, Khakharia A, Binney ZO, DeMartino RR, Brewster LP, Goodney PP,et al. Association of Statin Dose With Amputation and Survival in Patients With Peripheral Artery Disease. Circulation. 2018; 137:1435-1446

Key Points:

  1. In 155647 patients with incident PAD, identified from the national Veterans affairs data, it was found that high-intensity statins were underused.

 

  1. High-intensity statin use at the time of PAD diagnosis was associated with a significant reduction in limb loss and mortality in comparison with low-to-moderate–intensity statin users, and patients treated only with antiplatelet medications but not with statins.

Study Protocol:

Patients with incident PAD from 2003 to 2014 were identified from the national Veterans health administration data using a validated algorithm.

Statin use and dose/intensity (as defined by the 2013 ACC/AHA guidelines) by a veteran around their PAD diagnosis date (6 months before and after) was recorded.

The outcomes were

(1) Incident amputation (mid/hind foot, below- and above-knee amputations) and

(2) Death after PAD diagnosis during follow-up

A host of patient covariates was abstracted from the database.

Results:

 Out of 155647 patients with incident PAD, 28% were not on statins. High-intensity statin users were associated with lower amputation risk and mortality in comparison with antiplatelet therapy–only users (hazard ratio, 0.67; 95% confidence interval, 0.61–0.74 and hazard ratio, 0.74; 95% confidence interval, 0.70–0.77, respectively). Low-to-moderate–intensity statins also had significant reductions in the risk of amputation and mortality (hazard ratio amputation, 0.81; 95% confidence interval, 0.75– 0.86; hazard ratio death, 0.83; 95% confidence interval, 0.81–0.86) in comparison with no statins (antiplatelet therapy only), but effect was significantly weaker than the high-intensity statins (P<0.001). The results remained significant and robust in propensity score–matched, sensitivity, and subgroup analyses.

Conclusion:

There is lack of optimal use of statins in patients with PAD. High-intensity statin use at the time of PAD diagnosis is associated with a significant reduction in limb loss and mortality in comparison with low-to-moderate–intensity statin users, and patients treated only with antiplatelet medications.

Critical Appraisal:

Although the 2013 the American College of Cardiology/American Heart Association (ACC/AHA) guidelines on the treatment of blood cholesterol to reduce atherosclerotic cardiovascular risk in adults recommended that all patients with clinically apparent atherosclerotic cardiovascular disease should be initiated on high-intensity statins (3-hydroxy-3-methylglutaryl-coenzyme reductase inhibitors),  the level of evidence for PAD was low and based on data or risk estimates obtained from sub-cohorts of patients with CAD or isolated from population group estimates.

Hence, this largest and first of its kind study to examine the effect of statin use and intensity on mortality and amputation risk in a large cohort of patients with PAD assumes importance.

It shows that low-to-moderate–intensity statins were associated with a 17% reduction in mortality and a 19% reduction in amputation, whereas high-intensity statin therapy was associated with a 26% reduction in mortality and a 33% reduction in the risk of amputation in multivariable adjusted Cox regression models comparing statin users with the active comparator group.

To obviate the problem of residual confounding in this observational study, the investigators also performed a propensity score–matched analysis. In comparison with statin nonusers, high-intensity and low-to-moderate–intensity statin use were both associated with reductions in mortality (30% and 20%, respectively) and amputation (40% and 20%, respectively).

The study was limited by its observational design which raises doubts about additional unidentified confounders that account for the differences in clinical outcome between these groups. Also statin changes beyond the 1-year window used in the study is not known. Finally the results do not account for the initiation of additional therapies, such as smoking cessation or angiotensin-converting enzyme inhibitors, or clopidigrel use instead of aspirin use that could also explain some of the between-group differences.

Clinical Application:

As is evident from the study, there is still considerable underuse and recognition of the role of statins in patients with PAD, especially in those without coronary disease.

In patients with only PAD as their sole atherosclerotic disease process, about 42% were not on any statin medication and only 5.8% were on high-intensity statins.

The study shows that use of high-intensity statins early in peripheral artery disease (PAD) diagnosis is better in terms of decreasing the risk of amputation and death in patients with PAD.

Hence even if there is no evidence of disease in any other vascular territory, on diagnosis of PAD, a patient should be started on the highest intensity of statin that can be tolerated, to reduce their lifetime risk of amputation and death and this amplifies the need for education and dissemination among the medical fraternity caring for PAD.

Suggested readings:

  1. Stone NJ, Robinson JG, Lichtenstein AH, Bairey Merz CN, Blum CB, Eckel RH, et al. American College of Cardiology/American Heart Association Task Force on Practice Guidelines. 2013 ACC/AHA guideline on the treatment of blood cholesterol to reduce atherosclerotic cardiovascular risk in adults: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation. 2014;129(25 suppl 2):S1–S45
  2. Collins R, Armitage J, Parish S, Sleight P, Peto R; Heart Protection Study Collaborative Group. Effects of cholesterol-lowering with simvastatin on stroke and other major vascular events in 20536 people with cerebrovascular disease or other high-risk conditions. Lancet. 2004;363:757–767
  3. Aday AW and Brendan M. Everett. Statins in Peripheral Artery Disease. Circulation. 2018;137:1447-1449
">

Coronary Computed Tomography Angiography in asymptomatic people - Is it of any value?<.....

Coronary Computed Tomography Angiography in asymptomatic people - Is it of any value?<.....