Left ventricular contractile reserve as a determinant of adverse clinical outcomes: a systematic review.

An abnormal left ventricular contractile reserve is often seen in patients undergoing stress echocardiogram and may indicate the presence of obstructive coronary artery disease. The techniques and indexes used to identify abnormal left ventricular contractile response and its prognostic value in the absence of known causes has not been well studied. To describe the characteristics and clinical outcomes associated with an abnormal left ventricular contractile response, we performed a systematic review that identified 27 eligible studies. A diverse range of indices were utilised to measure left ventricular contractile reserve, most commonly Δleft ventricular ejection fraction in 11 studies. Dobutamine stress echocardiogram was the most commonly performed modality (19 studies) followed by exercise stress echocardiogram (4 studies), dipyridamole stress echocardiogram (2 studies), invasive hemodynamic measurement (1 study) and dobutamine stress magnetic resonance imaging (1 study). All but one study demonstrated a significant association between the absence of left ventricular contractile reserve and increased rate of cardiovascular events, cardiac death and all-cause mortality.

Gaps in the Care of Familial Hypercholesterolaemia in Australia: First Report From the National Registry.

BACKGROUND: Familial hypercholesterolaemia (FH) is under-diagnosed and under-treated worldwide, including Australia. National registries play a key role in identifying patients with FH, understanding gaps in care and advancing the science of FH to improve care for these patients. METHODS: The FH Australasia Network has established a national web-based registry to raise awareness of the condition, facilitate service planning and inform best practice and care services in Australia. We conducted a cross-sectional analysis of 1,528 FH adults enrolled in the registry from 28 lipid clinics. RESULTS: The mean age at enrolment was 53.4±15.1 years, 50.5% were male and 54.3% had undergone FH genetic testing, of which 61.8% had a pathogenic FH-causing gene variant. Only 14.0% of the cohort were family members identified through cascade testing. Coronary artery disease (CAD) was reported in 28.0% of patients (age of onset 49.0±10.5 years) and 64.9% had at least one modifiable cardiovascular risk factor. The mean untreated LDL-cholesterol was 7.4±2.5 mmol/L. 80.8% of patients were on lipid-lowering therapy with a mean treated LDL-cholesterol of 3.3±1.7 mmol/L. Among patients receiving lipid-lowering therapies, 25.6% achieved an LDL-cholesterol target of <2.5 mmol/L without CAD or <1.8 mmol/L with CAD. CONCLUSION: Patients in the national FH registry are detected later in life, have a high burden of CAD and risk factors, and do not achieve guideline-recommended LDL-cholesterol targets. Genetic and cascade testing are under-utilised. These deficiencies in care need to be addressed as a public health priority.

Predictors of acute hospital mortality and length of stay in patients with new-onset atrial fibrillation: a first-hand experience from a medical emergency team response provider.

BACKGROUND: Atrial fibrillation (AF) occurs frequently following cardiothoracic surgery and treatment decisions are informed by evidence-based clinical guidelines. Outside this setting there are few data to guide clinical management. AIM: To describe the characteristics, management and outcomes of hospitalised adult patients with new-onset AF. METHODS: The medical emergency team (MET) database was utilised to identify patients who had a 'MET call' activated for tachycardia between 2015 and 2016. Patients with sinus tachycardia, pre-existing AF/atrial flutter or other known tachyarrhythmia were excluded. Primary outcomes were length of hospital stay and in-hospital mortality. RESULTS: New-onset AF was identified in 137 patients: 68 medically managed; 38 non-cardiothoracic post-operative; and 31 cardiothoracic post-operative. Mean age was 74 ± 11.6 years and 72 (53%) were male. Of 79 patients who underwent echocardiography, 80% had left atrial dilatation and 14% had reduced left ventricular ejection fraction (LVEF). Mean length of stay (LOS) was 12 days and in-hospital mortality rate was 11%. On multivariable analysis, the odds of death during acute hospitalisation was 7.4 times higher in patients with heart failure with reduced LVEF (odds ratio 7.4, 95% confidence interval (CI) 1.23-44.8, P = 0.028). Length of acute hospital stay increased by 36% if the duration of AF was longer than 48 h (beta coefficient 0.36, 95% CI -0.015 to 0.74, P = 0.059). CONCLUSION: Left ventricular systolic dysfunction in hospitalised patients with new-onset AF is associated with increased all-cause mortality whereas lower serum potassium levels are associated with an increased LOS. A prospective study is planned to compare outcomes based on in-hospital treatment strategies.

A Small Change Can Make a Big Difference: A Lesson from Evolocumab.

BACKGROUND: Evolocumab is an expensive proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitor which has been shown to significantly improve cardiovascular outcomes in high risk patients. METHODS: This is a case study describing a stepwise approach to "PCSK9 inhibitor non-response" in a patient with familial hypercholesterolaemia. There are a few described pathophysiological mechanisms for "PCSK9 inhibitor non-response" including homozygous LDL-C receptor-negative mutations and alteration in the binding site of PCSK9 inhibitors. RESULTS: We report the case of a 41-year-old woman with familial hypercholesterolaemia and premature cardiovascular disease, who was non-responsive to the action of PCSK9 inhibitor solely due to the incorrect subcutaneous injection technique. CONCLUSIONS: This case study highlights the importance of reviewing the accuracy of SC injection technique in patients with minimal or no response to PCSK9 inhibitors prior to proceeding to costly genetic testing.

Preoperative Use of Oral Beta-Adrenergic Blocking Agents and the Incidence of New-Onset Atrial Fibrillation After Cardiac Surgery. A Systematic Review and Meta-Analysis.

BACKGROUND: Current epidemiological data suggests that postoperative atrial fibrillation or atrial flutter (POAF) causes significant morbidity and mortality after cardiac surgery. The literature for prophylactic management of POAF is limited, resulting in the lack of clear guidelines on management recommendations. AIM: To examine the efficacy of prophylactic rate control agents in reducing the incidence of new-onset POAF in patients undergoing elective cardiac surgery. METHODS: Cochrane Central Register of Controlled Trials (CENTRAL), Embase, and Medline were systematically searched for blinded randomised controlled studies (RCT) evaluating adults with no history of atrial fibrillation randomised to a pharmacological agent (either beta blocker, calcium channel blocker or digoxin), compared to placebo. Utilising Cochrane guidance, three reviewers screened, extracted and the quality of the evidence was assessed. We used a random effects meta-analysis to compare a rate-control agent with placebo. RESULTS: Five RCTs (688 subjects, mean age 61±8.9, 69% male) were included. Beta blocker administration prior to elective cardiac surgery significantly reduced the incidence of POAF (OR 0.43, 95%Cl [0.30-0.61], I2=0%) without significant impact on ischaemic stroke (OR 0.49, 95%Cl [0.10-2.44], I2=0%), non-fatal myocardial infarction (OR 0.76, 95%Cl [0.08-7.44], I2=0%), overall mortality (OR 0.83, 95%Cl [0.19-3.66], I2=0%), or length of stay (mean -0.96days 95%Cl [-1.49 to -0.42], I2=0%). An increased rate of bradycardic episodes was observed (OR 3.53, 95%Cl [1.22-10.23], I2=0%). CONCLUSIONS: This review suggests that selective administration of prophylactic oral beta blockers prior to elective cardiac surgery is safe and may reduce the incidence of POAF.

The utility of personal activity trackers (Fitbit Charge 2) on exercise capacity in patients post acute coronary syndrome [UP-STEP ACS Trial]: a randomised controlled trial protocol.

BACKGROUND: The benefits of physical activity and cardiovascular rehabilitation on the reduction of cardiovascular risk are well documented. Despite this, significant barriers and challenges remain in optimizing patient risk factors post acute coronary syndromes (ACS) and ensuring patient compliance. Consumer wearable personal activity trackers represent a cost effective and readily available technology that may aid in this endeavour. METHODS: UP-STEP ACS is a prospective single-blinded, two-arm, parallel, randomized control trial with an aim to enrol 200 patients all undertaking cardiac rehabilitation. It will assess the affect that personal activity monitors have on change in exercise capacity in patients post acute coronary syndromes primarily measured by a six-minute walk test (6MWT). Secondary end points will be the improvement in other cardiovascular risk factors, namely; blood lipid and glucose levels, weight, waist circumference, along with mood, quality of life and cardiac rehabilitation adherence. Patients will be randomized to either receive a personal activity tracker or standard post hospital care during their index event. After the 8- week intervention period, patients will return for a clinical review and repeat of baseline assessments including the 6MWT. DISCUSSION: The utility and impact on exercise capacity of personal activity trackers in patient's post-acute coronary syndrome has not been assessed. This study aims to add to the scientific evidence emerging regarding the clinical utility and validity of these devices in different patient population groups. If proven to be of benefit, these devices represent a cost effective, easily accessible technology that could aid in the reduction of cardiovascular events. TRIAL REGISTRATION: The trial has been registered with the Australian New Zealand Clinical Trials Registry (ANZCTR). The registration number is ACTRN12617000312347 (28/02/2017).

Update on the management of atrial fibrillation.

Atrial fibrillation (AF) is a common arrhythmia, with a prevalence that increases markedly with increasing age. Presence of AF has implications for management of future stroke risk. If the patient's pulse is irregular, an electrocardiogram should be ordered. Key management decisions are whether to adopt a rhythm control or a rate control strategy and whether to initiate anticoagulation. The primary aim of a rhythm control strategy is improved symptom control. AF ablation may be considered in younger patients (aged < 65 years) with paroxysmal or early persistent AF. AF increases the risk of stroke, and anticoagulation should be considered on the basis of stroke risk - clearly indicated with a CHADS 2 score (congestive heart failure, hypertension, age ≥ 75 years, diabetes, 1 point each; previous stroke or transient ischaemic attack, 2 points) of ≥ 2 - independent of the type of AF. In most patients with AF, the benefit of stroke reduction with systemic anticoagulation will outweigh its bleeding risks. All anticoagulants and antiplatelet agents increase the risk of bleeding. However, the new oral anticoagulants tend to have an improved safety profile, particularly in regard to intracranial bleeding, and are at least as effective as warfarin for stroke prevention.

Bleeding events associated with novel anticoagulants: a case series.

Until lately warfarin was the only valuable oral anticoagulant in stroke reduction in high risk cases with non valvular atrial fibrillation (NVAF). Although with warfarin the rate of stroke reduced notably, the major concern is the risk of serious bleeding and difficulty of establishing and maintaining the international normalised ratio (INR) within the therapeutic range. With the development of the novel anticoagulants we now have for the first time since the innovation of Warfarin feasible alternatives to it to decrease stroke rates in high risk patients with NVAF. To diminish adverse bleeding events with the novel anticoagulant proper selection of patients prior starting treatment is essential.

Effects of a 6-Month Multifaceted Diet and Exercise Intervention on Cognition in Older Adults at Risk of Cognitive Decline: The PONDER Double-Blind, Placebo-Controlled Randomized Trial.

BACKGROUND: Multidomain interventions which incorporate exercise and dietary supplementation to target both cognitive and physical health domains may be an important approach to delay cognitive decline. OBJECTIVE: The Protein Omega-3 aNd vitamin D Exercise Research (PONDER) study investigated the effects of a 6-month multifaceted intervention in community-dwelling older adults with subjective memory impairment on cognition (primary outcome), physical function, and body composition with a further 6-month follow up for cognition (secondary outcomes). METHODS: Single-center, community-based, parallel-group, randomized, double-blind placebo-controlled trial involving a 6-month multifaceted intervention with a further follow-up at 12 months. A total of 147 participants [mean age 70.2 years (SD 6.1), 70% female] were randomized to a multimodal exercise program consisting of twice-weekly supervised resistance and aerobic training, combined with a daily omega-3 (900 mg EPA, 600 mg DHA), vitamin D (1000 IU) and protein (20 g) supplement (n = 73), or a control condition (n = 74) comprising stretching/flexibility sessions combined with a placebo. The primary outcome was a composite CogState measure and Trail-Making Test B-A. RESULTS: There were no significant between-group differences in the change of cognition at 6 or 12 months or physical function outcomes at 6 months, but the intervention significantly improved total lean mass compared to controls [0.72 kg (95% CI 0.26-1.19), p = 0.001]. CONCLUSION: A multi-faceted intervention including an omega-3, vitamin D and protein-enriched supplement with twice-weekly exercise training did not provide any benefits to cognitive or physical function in older adults with subjective memory impairment, despite improvements in lean mass.

Long-term longevity and clinical outcomes of Linox S/SD implantable cardioverter-defibrillator leads: a single-center experience.

PURPOSE: Since the introduction of the Biotronik Linox S/SD leads in 2006, there have been multiple reports of premature lead failure. The purpose of this study was to investigate the longevity of the Linox S/SD leads and to identify the possible predictors of lead failure in a single tertiary implant center. METHODS: We retrospectively reviewed patients who underwent implantation of Linox S/SD leads or Sorin Vigila 1CR/2CR leads (the same Linox S/SD leads marketed by Sorin) at our center. The cumulative lead survival was estimated using the Kaplan-Meier curve, and variables associated with lead failure were assessed by Cox proportional hazard model. RESULTS: A total of 187 patients (154 (82%) male) underwent Linox S/SD or Vigila 1CR/2CR implantation between 2007 and 2013. During follow-up with a median time of 75 months, nine lead failures were identified (4.8%). The mean and median times from lead implantation to lead failure were 70.7 ± 21 months and 64 (45-111) months, respectively. The cumulative survival probability for the Linox S/SD at 5 years was 97.1% and at 12 years was 90.3%. Non-physiological high-rate sensing was the most common type of lead failure in patients. In two-thirds of these patients, this led to inappropriate shock. We did not find any significant relationships between patients' clinical and procedural characteristics and lead failure. CONCLUSIONS: At our center, the 5-year lead survival of the Linox S/SD has been better than reports from other centers. The majority of lead failures presented as non-physiological high-rate sensing with subsequent inappropriate therapy.

High-Dose Omega-3 Fatty Acids in Cardiovascular Prevention: Finally Living Up to Their Potential?

Despite the widespread use of statins in the setting of high cardiovascular risk, many patients continue to experience clinical events. This highlights the need to identify additional therapeutic strategies for high-risk patients. Interest in the use of omega-3 polyunsaturated fatty acids to prevent cardiovascular disease has been high for several decades. Despite promising results from before the statin era, many clinical trials have produced disappointing findings regarding products containing conventional doses of omega-3 fatty acids. More recent clinical trials using high doses of omega-3 fatty acids in targeted populations have suggested potential benefit when targeting the risk driven by atherogenic dyslipidemia. We review the clinical implications of completed and ongoing trials.

Impact of Side-Branch Predilation on Angiographic Outcomes in Non-Left Main Coronary Bifurcation Lesions.

BACKGROUND: Despite the high prevalence of coronary bifurcation lesions in routine interventional cardiology practice, the best strategy for managing this challenging lesion subset remains debatable. Due to potential for complications, the routine practice of side-branch (SB) predilation is controversial. METHODS: An electronic search was performed of online databases up until April 2018 for studies reporting periprocedural angiographic outcomes comparing provisional main-branch stenting with and without SB predilation. Random-effects model odds ratios (ORs) were calculated. RESULTS: Eight studies were selected for a qualitative review, with 47.3% (1367/2890) of included subjects having angiographic outcomes following SB predilation reported. Of these, four studies included details of periangiographic outcomes comparing two groups. Bifurcation lesions stented without SB predilation demonstrated lower odds of requiring further SB intervention compared with lesions receiving upfront SB predilation (OR, 2.44; 95% confidence interval [CI], 1.71-3.47; I²=21%; P<.001). No difference was demonstrated regarding final SB TIMI flow <3, SB dissection, or intraprocedural SB occlusion. Although the odds of performing final kissing-balloon inflation were in favor of the group without SB predilation (OR, 1.62; 95% CI, 1.11-2.37; I²=61%; P=.01), there was no statistical difference in long-term major cardiovascular outcome (MACE) between the two groups (risk ratio, 1.29; 95% CI, 0.94-1.75; I²=11%; P=.33). CONCLUSION: SB predilation during coronary bifurcation percutaneous coronary intervention did not alter overall procedural angiographic outcomes. However, SB predilation is associated with increased SB intervention, including increased requirement for SB stenting, without demonstrable long-term MACE benefit, compared with a standard strategy without SB predilation.

Junctional ectopic tachycardia (JET).

Junctional ectopic tachycardia (JET) is a tachyarrhythmia arising from the atrioventricular node and His bundle area. Enhanced normal automaticity has been postulated as the mechanism of JET in the majority of patients. It is more common in children and can be seen as congenital or in postoperative settings. It is often a narrow complex tachycardia but can present as a wide complex tachycardia as a result of aberrant conduction. Its differentiation from other arrhythmias especially atrioventricular nodal reentrant tachycardia (AVNRT) can be challenging. Medical treatment of JET is difficult, and catheter ablation remains the mainstay of treatment in refractory cases with a high risk of atrioventricular block and recurrence.

Familial Hypercholesterolemia With Coexisting Renovascular Stenosis and Premature Coronary Artery Disease.

Familial hypercholesterolemia (FH) is a common hereditary lipid disorder associated with substantial risk of premature atherosclerotic cardiovascular disease. We report an interesting newly diagnosed index case of FH in a 31-year-old man who presented to the hospital with an ST-elevated myocardial infarction. He had a background of inadequately treated hypertension and hypercholesterolemia. Further investigations raised the possibility of secondary hypertension after the identification of renal artery stenosis, in addition to other areas of mesenteric arterial stenoses. Our patient's case highlights that early-onset hypertension and hypercholesterolemia in a young individual may be an early manifestation of FH requiring high clinical vigilance and awareness.

Multifaceted intervention to enhance cognition in older people at risk of cognitive decline: study protocol for the Protein Omega-3 and Vitamin D Exercise Research (PONDER) study.

INTRODUCTION: An increasing number of people are living with cognitive impairment and dementia. Current pharmacological therapies at best reduce Alzheimer's disease symptomatology but do not delay dementia onset in those at high risk. Structured exercise interventions can enhance cognition in older people; however, to produce long lasting, clinically relevant cognitive benefits, it is proposed that a multifaceted approach incorporating exercise with dietary supplements will address a wider range of mechanisms involved in cognitive decline. The Protein Omega-3 aNd vitamin D Exercise Research (PONDER) study aims to investigate the cognitive effects of a multimodal exercise programme combined with nutritional supplementation in older adults with subjective memory impairment (SMI). METHODS AND ANALYSIS: The PONDER study is a single-centre, 12-month, community-based, parallel group, randomised, double-blind, placebo controlled trial involving a 6-month multifaceted intervention with a further 6-month follow-up. Participants will be 148 people from Melbourne, Australia, aged 60-85 years with SMI who will be randomised (1:1 ratio) to either a 6-month supervised multimodal exercise programme combined with omega-3 fatty acid, vitamin D and protein supplementation or a stretching/flexibility exercise programme combined with placebo supplements. The primary outcome is the change in cognition after 6 months as assessed by the Trail Making Test and global cognitive function assessed from the Cogstate Computerised battery. Secondary outcomes will include memory, working memory/learning and attention/psychomotor function, the Montreal Cognitive Assessment, mood, quality of life, muscle strength, physical function, body composition, cardiovascular health and sleep quality. Cognition at 12 months will represent a secondary outcome. ETHICS AND DISSEMINATION: This study has been approved by the Deakin University Human Research Ethics Committee (project 2016-260). Informed consent will be obtained from all participants. The authors intend to submit the findings of the study to peer-reviewed journals or academic conferences to be published. TRIAL REGISTRATION NUMBER: ACTRN12616001549415; Pre-results.

The tertiary hospital laboratory; a novel avenue of opportunistic screening of familial hypercholesterolemia.

BACKGROUND: Familial hypercholesterolemia (FH) is a common monogenic hereditary lipid disorder characterised by increased serum low-density lipoprotein cholesterol (LDL-cholesterol) concentrations and high risk of premature atherosclerotic cardiovascular disease. The prevalence of FH identified in a tertiary hospital laboratory was investigated by performing an opportunistic screen for index cases. METHODS: The prevalence of likely FH based on LDL-cholesterol thresholds >4.9 mmol/L as employed by the Dutch Lipid Clinic Network Criteria (DLCNC) score was evaluated retrospectively in a single tertiary hospital laboratory over a six-month period (July to December 2016). RESULTS: 4943 lipid profiles screened, 106 patients (mean age 53.2 ±â€¯12.9 and 41% male) had LDL-cholesterol of >4.9 mmol/L after exclusion of 5 patients (0.1%) with secondary causes. Possible (n = 90) and probable/definite (n = 16) FH according to DLCNC score was seen in 1.8% and 0.4% of the overall screened population, respectively. CONCLUSIONS: Point prevalence of screening for FH in patients undergoing lipid profile testing in a tertiary hospital laboratory was comparable with prevalence of FH in general population (based on 1 in 200-250). This supports the benefit of establishing an efficient "alert system" in conjunction with a trigger "reflex testing" to facilitate further formal FH scoring and exclusion of possible secondary causes of hyperlipidemia in potential index FH.

Awareness of Familial Hypercholesterolemia Among Healthcare Providers Involved in the Management of Acute Coronary Syndrome in Victoria, Australia.

BACKGROUND: Familial hypercholesterolemia (FH) is a common underdiagnosed autosomal dominant lipid disorder carrying a significant risk of premature coronary artery disease. The aim of this study was to evaluate the awareness and knowledge of heterozygous FH of healthcare providers in coronary care units (CCUs). METHODS: Medical staff working in CCUs in 4 sizable metropolitan health networks in Melbourne, Australia, were requested to complete a structured anonymised questionnaire with regard to FH. The results were tabulated and analysed with the Statistical Package for the Social Sciences version 23 (IBM, New York, NY). RESULTS: A total of 121 participants (67% response rate) completed the survey. Some 76% claimed to be at least modestly familiar with FH, and more than half of them adequately described FH; however, only 16% and 43%, respectively, were aware of the prevalence of FH and existence of lipid guidelines. In regard to epidemiological knowledge and update in the management of FH in CCUs, knowledge was suboptimal. In regard to FH care, General Practitioners were rated by 72% of participants as the first most efficient healthcare provider in the management of FH, and cardiologists were rated by 54% of participants as the second most efficient healthcare provider in the management of FH. Some 36% of respondents advocated a form of alert system in laboratory reports to facilitate the diagnosis of FH. CONCLUSIONS: This survey identified substantial gaps in the knowledge and awareness of FH among healthcare providers involved in the management of acute coronary syndrome. Focused education and clinical training are warranted to raise awareness of FH among healthcare providers working in CCUs.

CONTEXTE: L'hypercholestérolémie familiale (HF) est un trouble lipidique autosomique dominant courant et sous-diagnostiqué, associé à un risque important de coronaropathie prématurée. Le but de cette étude consistait à évaluer la sensibilisation et les connaissances à l'égard de l'HF hétérozygote parmi les professionnels de la santé œuvrant en unité de soins coronariens (USC). MÉTHODOLOGIE: Les membres du personnel médical des USC de quatre réseaux de santé métropolitains relativement importants de Melbourne, en Australie, ont été invités à remplir un questionnaire anonyme structuré sur l'HF. Les résultats ont été mis sous forme de tableaux et analysés à l'aide de la trousse logicielle SPSS (Statistical Package for the Social Sciences, IBM, New York, NY), version 23. RÉSULTATS: Au total, 121 personnes (taux de réponse de 67 %) ont participé à l'enquête. Environ 76 % des répondants ont indiqué posséder à tout le moins quelques connaissances sur l'HF, tandis que plus de la moitié d'entre eux en ont donné une définition adéquate; en revanche, seuls 16 et 43 %, respectivement, connaissaient la prévalence de l'HF et l'existence de lignes directrices sur les lipides. Par rapport aux connaissances épidémiologiques et à l'actualisation des stratégies de prise en charge de l'HF en USC, les connaissances étaient sous-optimales. Soixante-douze pour cent des répondants ont jugé que le médecin généraliste était le professionnel de la santé le plus à même de soigner et de prendre en charge l'HF; le cardiologue a été mentionné en seconde position par 54 % des répondants. Quelque 36 % des répondants ont préconisé la mise en place d'un système d'alerte, dans les rapports de laboratoire, pour faciliter le diagnostic d'HF. CONCLUSIONS: Cette enquête a mis en évidence des lacunes considérables dans la sensibilisation et les connaissances à l'égard de l'HF parmi les professionnels de la santé intervenant dans la prise en charge du syndrome coronarien aigu. Un enseignement et une formation clinique ciblés s'imposent pour accroître la sensibilisation à l'égard de l'HF parmi les professionnels de la santé qui travaillent en USC.

Biodegradable-Polymer Versus Polymer-Free Drug-Eluting Stents for the Treatment of Coronary Artery Disease.

BACKGROUND/PURPOSE: Biodegradable-polymer (BP) and polymer-free (PF) drug eluting stents (DES) were developed to reduce the risk of delayed arterial healing observed with durable-polymer (DP) platforms. Although trials demonstrate BP-DES and PF-DES are non-inferior to DP-DES, there is limited data directly comparing these technologies. We performed a meta-analysis to assess the efficacy and safety of BP-DES versus PF-DES for the treatment of coronary artery disease. METHODS/MATERIALS: Electronic searches were performed identifying randomized trials comparing BP-DES with PF-DES. Co-primary efficacy endpoints were target vessel revascularization (TVR), target lesion revascularization (TLR) and angiographic in-stent late lumen loss (LLL). Co-secondary safety endpoints were all-cause death, myocardial infarction (MI) and stent thrombosis (ST). RESULTS: Of 208 studies, 5 met inclusion criteria including 1975 patients. At mean follow-up (14 ±â€¯5 months), BP-DES were associated with significantly reduced rates of TVR (OR 0.58, 95%CI 0.37-0.92, p = 0.02), TLR (4.7% vs 9.5%) (OR 0.48, 95%CI 0.31-0.75, p = 0.001) and in-stent LLL (pooled mean difference -0.20 mm, 95%CI -0.24 to -0.16, p < 0.001). There was no difference in safety, including all-cause death (OR 1.24, 95%CI 0.68-2.28, p = 0.48), MI (OR 0.92, 95%CI 0.54-1.56, p = 0.75) or ST (OR 1.58, 95%CI 0.67-3.73, p = 0.30). CONCLUSIONS: These data suggests that BP-DES are more efficacious when compared with PF-DES for the treatment of CAD.

Remnant cholesterol and coronary atherosclerotic plaque burden assessed by computed tomography coronary angiography.

BACKGROUND AND AIMS: There remains a substantial residual risk of ischaemic heart disease (IHD) despite optimal low-density lipoprotein cholesterol (LDLC) reduction. Part of this risk may be attributable to remnant cholesterol, which is carried in triglyceride-rich lipoproteins. We evaluated the relationship between remnant cholesterol and coronary atherosclerotic plaque burden assessed non-invasively by computed tomography coronary angiography (CTCA) in patients with suspected coronary artery disease (CAD). METHODS AND RESULTS: This was a multicentre study of 587 patients who had a CTCA and fasting lipid profile within 3 months. Calculated remnant cholesterol was total cholesterol minus LDLC minus high-density lipoprotein cholesterol (HDLC). Significant coronary atherosclerotic burden was defined as CT-Leaman score >5 (CT-LeSc), an established predictor of cardiac events. Mean age was 61 ±â€¯12 years and mean pretest probability of CAD was 23.2 ±â€¯19.8%. LDLC levels were <1.8 mmol/L in 134 patients (23%), of whom 82% were statin-treated. Patients with CT-LeSc >5 had higher mean remnant cholesterol than those with CT-LeSc ≤5 (0.76 ±â€¯0.36 mmol/L vs. 0.58 ±â€¯0.33 mmol/L, p = 0.01). On univariable analysis, remnant cholesterol (p = 0.01), LDLC (p = 0.002) and HDLC (p < 0.001) levels predicted CT-LeSc >5, whilst triglycerides (p = 0.79) had no association with CT-LeSc >5. On multivariable analysis in the subset of patients with optimal LDLC levels, remnant cholesterol levels remained predictive of CT-LeSc >5 (OR 3.87, 95% confidence interval 1.34-7.55, p = 0.004), adjusted for HDLC and traditional risk factors. CONCLUSIONS: Remnant cholesterol levels are associated with significant coronary atherosclerotic burden as assessed by CTCA, even in patients with optimal LDLC levels. Future studies examining whether lowering of remnant cholesterol can reduce residual IHD risk are warranted.

The effect of combined ezetimibe and statin therapy versus statin therapy alone on coronary plaque volume assessed by intravascular ultrasound: A systematic review and meta-analysis.

BACKGROUND: Current guidelines recommend an intensive lipid-lowering therapy to achieve the low-density lipoprotein cholesterol (LDL-C) target in patients with high risk of cardiovascular disease. Former studies suggested adding ezetimibe to statin therapy in the above setting may promote plaque changes; however, this effect has not been consistently reported. METHODS: Electronic searches were performed in MEDLINE, EMBASE, and Cochrane library on November 30, 2017 to identify prospective trials assessing the effects of combined ezetimibe and statin therapy versus statin therapy alone on atheroma volume using intravascular ultrasound. The effect size between treatment groups within individual studies was assessed by weighted mean difference (MD) using a random-effects model. RESULTS: Eight studies were obtained for systematic review and 6 of them compromising total of 583 subjects that meet the criteria were meta-analyzed. There was a significant reduction from baseline to follow-up in total atheroma volume with an MD of -3.71 mm3 (95% confidence interval: -5.98 to -1.44, P < .001), whereas analysis for percent atheroma volume demonstrated weighted MD of - 0.77% (-1.68 to 0.14, P = .10). A substantial decrease in LDL-C was observed with MD -16.75 mg/dL (-20.89 to -12.60, P < .00001). CONCLUSION: The addition of ezetimibe to statin therapy is effective in reducing total atheroma volume assessed by intravascular ultrasound and also resulted in effective reduction of plasma LDL-C levels.