Systematic Review on Role of Drug Eluting Stent (DES) Versus Drug-Coated Balloon (DCB) in Small Vessel Coronary Artery Disease.

PURPOSE OF REVIEW: This review aims to explain the current advancements in the treatment modalities for small vessel coronary artery disease (SVCAD) and de novo lesions post-percutaneous coronary intervention (PCI), focusing on drug-coated stents (DES) and drug-coated balloons (DCB). Its goal is to address the lack of standards in the management of these lesions and to assess the potential of DCB as a preferential treatment strategy over DES in the long term. RECENT FINDINGS: Technological advancements have improved drug-eluting stents (DES) and drug-coated balloons (DCB) which offer a more promising avenue for managing SVCAD. According to new data, DCBs, initially recognized for their efficacy in preventing restenosis within three to five years of stent placement, may offer superior outcomes compared to DES in certain clinical scenarios. This review shows that DCBs have a favorable therapeutic profile in the treatment of SVCAD, and they could be considered as an alternative to DES. Although the initial data is compelling, definitive conclusions cannot be met without further large-scale, long-term clinical trials. The implication of these findings suggests a shift in the future of SVCAD management and requires additional research to substantiate the long-term benefits of DCB use in SVCAD. Should ongoing and future studies corroborate the current evidence, DCB could emerge as the standard of care for SVCAD, significantly influencing clinical practices and future research.

Private Equity and Cardiovascular Health Care.

This Viewpoint discusses involvement of private equity firms in health care.

To Anticoagulate or Not to Anticoagulate in COVID-19: Lessons after 2 Years.

A hypercoagulable state associated with coronavirus disease 2019 (COVID-19) has been well documented and is believed to be strongly supported by a proinflammatory state. The hypercoagulable state in turn results in increased incidence of arterial and venous thromboembolism (VTE) seen in hospitalized COVID-19 when compared with hospitalized non-COVID-19 patient cohorts. Moreover, patients with arterial or VTE and COVID-19 have higher mortality compared with COVID-19 patients without arterial or VTE. Prevention of arterial or VTE thus remains an essential question in the management of COVID-19 patients, especially because of high rates of reported microvascular and macrovascular thrombosis. This has prompted multiple randomized control trials (RCTs) evaluating different anticoagulation strategies in COVID-19 patients at various stages of the disease. Herein, we review findings from RCTs in the past 2 years of antithrombotic therapy in critically ill hospitalized patients, noncritically ill hospitalized patients, patients postdischarge from the hospital, and outpatients. RCTs in critically ill patients demonstrated therapeutic dose anticoagulation does not improve outcomes and has more bleeding than prophylaxis dose anticoagulant in these patients. Trials in noncritically ill hospitalized patients showed a therapeutic dose anticoagulation with a heparin formulation might improve clinical outcomes. Anticoagulation with a direct oral anticoagulant posthospital discharge may improve outcomes, although there is a large RCT in progress. Nonhospitalized COVID-19 patients have an insufficient burden of events to be candidates for antithrombotic therapy. Anticoagulation in pregnant and lactating patients with COVID-19, as well as antiplatelet therapy for COVID-19, is also reviewed.

Does the ISCHEMIA Trial Apply to My Patients?

PURPOSE OF REVIEW: The ISCHEMIA trial demonstrated no difference in myocardial infarction or death in patients with stable coronary disease and moderate or large ischemia territory treated either with invasive revascularization or optimal medical therapy. Whether the findings of the randomized control trial relates to real-world outcomes is uncertain. RECENT FINDINGS: Contemporary guideline-directed medical therapy has had a significant impact on the prognosis of coronary artery disease. Various observational data appear to indicate limited generalizability of the ISCHEMIA trial in different populations. Further studies are warranted to evaluate the optimal modality of therapy in patients with stable coronary disease and moderate or severe ischemia. The applicability of ISCHEMIA and ISCHEMIA-CKD trials still requires further validation.

Clinical Characteristics and Pharmacological Management of COVID-19 Vaccine-Induced Immune Thrombotic Thrombocytopenia With Cerebral Venous Sinus Thrombosis: A Review.

Importance: The COVID-19 pandemic saw one of the fastest developments of vaccines in an effort to combat an out-of-control pandemic. The 2 most common COVID-19 vaccine platforms currently in use, messenger RNA (mRNA) and adenovirus vector, were developed on the basis of previous research in use of this technology. Postauthorization surveillance of COVID-19 vaccines has identified safety signals, including unusual cases of thrombocytopenia with thrombosis reported in recipients of adenoviral vector vaccines. One of the devastating manifestations of this syndrome, termed vaccine-induced immune thrombotic thrombocytopenia (VITT), is cerebral venous sinus thrombosis (CVST). This review summarizes the current evidence and indications regarding biology, clinical characteristics, and pharmacological management of VITT with CVST. Observations: VITT appears to be similar to heparin-induced thrombocytopenia (HIT), with both disorders associated with thrombocytopenia, thrombosis, and presence of autoantibodies to platelet factor 4 (PF4). Unlike VITT, HIT is triggered by recent exposure to heparin. Owing to similarities between these 2 conditions and lack of high-quality evidence, interim recommendations suggest avoiding heparin and heparin analogues in patients with VITT. Based on initial reports, female sex and age younger than 60 years were identified as possible risk factors for VITT. Treatment consists of therapeutic anticoagulation with nonheparin anticoagulants and prevention of formation of autoantibody-PF4 complexes, the latter being achieved by administration of high-dose intravenous immunoglobin (IVIG). Steroids, which can theoretically inhibit the production of new antibodies, have been used in combination with IVIG. In severe cases, plasma exchange should be used for clearing autoantibodies. Monoclonal antibodies, such as rituximab and eculizumab, can be considered when other therapies fail. Routine platelet transfusions, aspirin, and warfarin should be avoided because of the possibility of worsening thrombosis and magnifying bleeding risk. Conclusions and Relevance: Adverse events like VITT, while uncommon, have been described despite vaccination remaining the most essential component in the fight against the COVID-19 pandemic. While it seems logical to consider the use of types of vaccines (eg, mRNA-based administration) in individuals at high risk, treatment should consist of therapeutic anticoagulation mostly with nonheparin products and IVIG.

Mechanical Complications in ST-Elevation Myocardial Infarction (STEMI) Based on Different Reperfusion Strategies.

Contemporary trends of mechanical complications like papillary muscle rupture (PMR), ventricular septal defect/rupture (VSR), and free wall rupture (FWR) in ST-elevation m'yocardial infarction (STEMI), especially in the era of primary percutaneous coronary interventions (PPCI) has not been definitively investigated. We utilized the National Inpatient Sample (NIS) database from years 2003 to 2017 using International Classification of Disease 9th and 10th revision (ICD-9 and ICD-10) codes to identify STEMI patients undergoing PPCI, fibrinolysis alone, and fibrinolysis with subsequent PCI. We identified those developing in-hospital PMR /VSD / FWR. We identified a total of 2,034,153 STEMI patients where 93.5% had PPCI, 3.2% had fibrinolysis alone, and 3.3% had fibrinolysis with subsequent PCI. Rates of all mechanical complications was low for all three different reperfusion strategies evaluated, with downward trends (p <0.05) over time. No statistically significant difference in the rates of mechanical complication was noted among patients treated with different reperfusion strategies on multivariable logistic regression models. In conclusion, in a contemporary cohort of US patients-majority of whom were managed with PPCI, the rates of overall mechanical complications after STEMI were low even with initial use of fibrinolytics and exhibited a downward temporal trend.

Chronic mesenteric ischemia: Diagnosis and management.

Chronic mesenteric ischemia (CMI) is an uncommon, potentially underdiagnosed clinical condition. Although there is a high prevalence of mesenteric artery stenoses (MAS), an abundant collateral network in the mesenteric circulation mitigates occurrence of ischemia. The most common etiology of CMI is atherosclerosis. CMI is a clinical diagnosis, based upon typical and atypical symptoms and consistent anatomic findings. Typical symptoms of CMI are postprandial abdominal pain, unintended weight loss and food avoidance. The main modalities to diagnose MAS are duplex ultrasound, CT angiography or MR angiography, although high resolution CTA is preferred. Endovascular therapy with balloon expandable stents has become the preferred treatment for MAS.

Predictors of Treatment Response Following Ultrasound-Facilitated Catheter-Directed Thrombolysis for Submassive and Massive Pulmonary Embolism: A SEATTLE II Substudy.

BACKGROUND: Little is known about which factors predict improvement in clinical and imaging parameters among patients undergoing catheter-directed thrombolysis for submassive or massive pulmonary embolism. The identification of such predictors may allow for more appropriate patient selection for ultrasound-facilitated catheter-directed thrombolysis. METHODS: We conducted a retrospective cohort analysis of patients from the SEATTLE II trial (Prospective, Single-Arm, Multi-Center Trial of EkoSonic Endovascular System and Activase for Treatment of Acute Pulmonary Embolism) to identify clinical characteristics that independently predict pulmonary artery pressures, right ventricular-to-left ventricular (RV/LV) diameter ratio, and modified Miller angiographic index following ultrasound-assisted catheter-directed thrombolysis. Eligible patients had submassive or massive pulmonary embolism and an RV/LV diameter ratio ≥0.9 on chest computed tomography. Multivariable linear regression was used to identify independent clinical predictors of each outcome. RESULTS: One hundred fifty patients with massive (n=31) or submassive (n=119) pulmonary embolism were enrolled. Mean (±SD) baseline and postprocedure RV/LV diameter ratio, pulmonary artery systolic pressure, and modified Miller Score were 1.59 (±0.39) and 1.14 (±0.2), 51.45 (±16.0), and 37.47 (±11.9), and 23.0 (±5.7) and 15.7 (±5.9), respectively. The multivariable model adjusted R2 for absolute change in RV/LV ratio, pulmonary artery systolic pressure, modified Miller Score was 0.71, 0.57, and 0.43, respectively. After adjusting for age, gender, and baseline RV/LV ratio, pulmonary artery systolic pressure, and modified Miller Score, patients with higher body mass index, renal or hepatic dysfunction, active smoking, or a higher baseline heart rate showed less improvement. CONCLUSIONS: Patients with more life-threatening pulmonary embolism may derive the greatest benefit from ultrasound-assisted, catheter-directed thrombolysis.

Cardiovascular Outcomes with Transcatheter vs. Surgical Aortic Valve Replacement in Low-Risk Patients: An Updated Meta-Analysis of Randomized Controlled Trials.

BACKGROUND: TAVR is an established treatment option in high and intermediate-risk patients with severe AS. There is less data regarding the efficacy of TAVR in low-risk patients. This meta-analysis evaluated efficacy and safety outcomes of transcatheter aortic valve replacement (TAVR) in comparison to surgical aortic valve replacement (SAVR) in low-risk patients with severe aortic stenosis (AS). METHODS: Databases were searched for randomized controlled trials (RCTs) that compared TAVR with SAVR for the treatment of low-risk patients with severe AS. We calculated pooled odds ratios (ORs) and 95% confidence intervals (CIs) using the random-effects model. RESULTS: The final analysis included 2953 patients from 5 studies. Compared to SAVR, TAVR was associated with similar mid-term mortality [OR 0.67; 95% CI 0.37-1.21; p = 0.18], as well as similar short-term mortality [OR 0.51; 95% CI 0.24-1.11; p = 0.09]. Randomization to TAVR was associated with a reduced risk of developing acute kidney injury [OR 0.26; 95% CI 0.13-0.52; p < 0.001], short-term major bleeding [OR 0.27; 95% CI 0.12-0.60; p < 0.001] and new-onset atrial fibrillation [OR 0.17; 95% CI 0.14-0.21; p < 0.001]. However, TAVR was associated with a higher risk of requiring permanent pacemaker implantation [OR 4.25; 95% CI 1.86-9.73; p < 0.001]. There was no significant difference in the risk of myocardial infarction, stroke, endocarditis or aortic valve re-intervention between the two groups. CONCLUSIONS: Our meta-analysis showed that TAVR has similar clinical efficacy to SAVR, with a more favorable safety profile, in patients with severe AS who are at low-surgical risk.

Impact of Artificial Intelligence on Interventional Cardiology: From Decision-Making Aid to Advanced Interventional Procedure Assistance.

Access to big data analyzed by supercomputers using advanced mathematical algorithms (i.e., deep machine learning) has allowed for enhancement of cognitive output (i.e., visual imaging interpretation) to previously unseen levels and promises to fundamentally change the practice of medicine. This field, known as "artificial intelligence" (AI), is making significant progress in areas such as automated clinical decision making, medical imaging analysis, and interventional procedures, and has the potential to dramatically influence the practice of interventional cardiology. The unique nature of interventional cardiology makes it an ideal target for the development of AI-based technologies designed to improve real-time clinical decision making, streamline workflow in the catheterization laboratory, and standardize catheter-based procedures through advanced robotics. This review provides an introduction to AI by highlighting its scope, potential applications, and limitations in interventional cardiology.

Etiologies, trends, and predictors of readmission in ST-elevation myocardial infarction patients undergoing multivessel percutaneous coronary intervention.

BACKGROUND: Recent trials have shown benefits with percutaneous coronary intervention (PCI) on nonculprit coronary vessels in select ST-elevation myocardial infarction (STEMI) patients with multivessel coronary artery disease (CAD). However, readmission rates and causes in this high-risk group are unknown. Objective of this study is to explore pattern, causes and factors associated with 30-day readmission after multivessel PCI in STEMI patients. METHODS AND RESULTS: Nationwide Readmissions Data (NRD) between 2010 and 2014 was utilized to identify multivessel PCI cases in STEMI patients using appropriate ICD-9 codes. We evaluated 30-day readmission rate and factors associated with 30-day readmission. Hierarchical logistic regression model was used to identify factors associated with 30-day readmission. Among 22,257 STEMI patients who survived to discharge after multivessel PCI, 2,302 (10.3%) were readmitted within 30-days. Subsequent unresolved/aggravated cardiac issues most commonly triggered readmission (62.66%). Among cardiac causes, heart failure and ischemic heart disease were most frequent etiologies. Advancing age (OR: 1.073, 95%CI: 1.026 to 1.122, p = .002), female sex (OR: 1.36, 95%CI: 1.23 to 1.50, p < .001), comorbid conditions like chronic kidney disease (CKD; OR: 1.35, 95%CI: 1.17 to 1.57, p = .001), congestive heart failure (CHF; OR: 1.40, 95%CI: 1.24 to 1.57, p = .04), anemia (OR: 1.16, 95%CI: 1.002 to 1.34, p = .04), and utilization of a mechanical circulatory support (MCS) device (OR: 1.45, 95%CI: 1.19 to 1.77, p < .001) during the index procedure were predictive of subsequent readmission within 30 days. CONCLUSION: In this large nationally representative study, nearly one in 10 patients were readmitted within 30 days from discharge after index admission for multivessel PCI in STEMI, most commonly for cardiac causes.

Sham-Controlled Randomized Trials of Catheter-Based Renal Denervation in Patients With Hypertension.

BACKGROUND: There are conflicting data regarding the relative effectiveness of renal sympathetic denervation (RSD) in patients with hypertension. OBJECTIVES: The purpose of this study was to evaluate the blood pressure (BP) response after RSD in sham-controlled randomized trials. METHODS: Databases were searched through June 30, 2018. Randomized trials (RCTs) with ≥50 patients comparing catheter-based RSD with a sham control were included. The authors calculated summary treatment estimates as weighted mean differences (WMD) with 95% confidence intervals (CIs) using random-effects meta-analysis. RESULTS: The analysis included 977 patients from 6 trials. The reduction in 24-h ambulatory systolic blood pressure (ASBP) was significantly greater for patients treated with RSD than sham procedure (WMD -3.65 mm Hg, 95% CI: -5.33 to -1.98; p < 0.001). Compared with sham, RSD was also associated with a significant decrease in daytime ASBP (WMD -4.07 mm Hg, 95% CI: -6.46 to -1.68; p < 0.001), office systolic BP (WMD -5.53 mm Hg, 95% CI: -8.18 to -2.87; p < 0.001), 24-h ambulatory diastolic BP (WMD -1.71 mm Hg, 95% CI: -3.06 to -0.35; p = 0.01), daytime ambulatory diastolic BP (WMD -1.57 mm Hg, 95% CI: -2.73 to -0.42; p = 0.008), and office diastolic BP (WMD -3.37 mm Hg, 95% CI: -4.86 to -1.88; p < 0.001). Compared with first-generation trials, a significantly greater reduction in daytime ASBP was observed with RSD in second-generation trials (6.12 mm Hg vs. 2.14 mm Hg; p interaction = 0.04); however, this interaction was not significant for 24-h ASBP (4.85 mm Hg vs. 2.23 mm Hg; p interaction = 0.13). CONCLUSIONS: RSD significantly reduced blood pressure compared with sham control. Results of this meta-analysis should inform the design of larger, pivotal trials to evaluate the long-term efficacy and safety of RSD in patients with hypertension.

Dual antithrombotic therapy in PCI: Potential harm in routine adoption.

Randomized clinical trials support the use of dual antithrombotic therapy (DAT) in PCI patients but outcomes in clinical practice are unclear. In this observational study of patients at high risk for thromboembolism and bleeding, routine use of a P2Y12 inhibitor alone compared with DAPT with OAC was associated with a significantly higher risk of ischemic events without a lower risk of bleeding. Future randomized trials and observational analyses of large registries are needed to select the ideal patient population for DAT.