Statins and statin intensity in peripheral artery disease.

Background: Peripheral artery disease (PAD) affects more than 202 million people worldwide. Several studies have shown that patients with PAD are often undertreated, and that statin utilization is suboptimal. European and American guidelines highlight statins as the first-line lipid-lowering therapy to treat patients with PAD. Our objective with this meta-analysis was to further explore the impact of statins on lower extremities PAD endpoints and examine whether statin dose (high vs. low intensity) impacts outcomes. Patients and methods: We performed a systematic review and meta-analysis according to the PRISMA guidelines. Any study that presented a comparison of use of statins vs. no statins for PAD patients or studies comparing high vs. low intensity statins were considered to be potentially eligible. We excluded studies with only critical limb threatening ischemia (CLTI) patients. The Medline (PubMed) database was searched up to January 31, 2021. A random effects meta-analysis was performed. Results: In total, 39 studies and 275,670 patients were included in this meta-analysis. In total, 136,025 (49.34%) patients were on statins vs. 139,645 (50.66%) who were not on statins. Statin use was associated with a reduction in all cause-mortality by 42% (HR: 0.58, 95% CI: 0.49-0.67, p<0.01) and cardiovascular death by 43% (HR: 0.57, 95% CI: 0.40-0.74, p<0.01). Statin use was associated with an increase in amputation-free survival by 56% (HR: 0.44, 95% CI: 0.30-0.58, p<0.01). The risk of amputation and loss of patency were reduced by 35% (HR: 0.65, 95% CI: 0.41-0.89, p<0.01) and 46% (HR: 0.54, 95% CI: 0.34-0.74, p<0.01), respectively. Statin use was also associated with a reduction in the risk of major adverse cardiovascular events (MACE) by 35% (HR: 0.65, 95% CI: 0.51-0.80, p<0.01) and myocardial infarction rates by 41% (HR: 0.59, 95% CI: 0.33-0.86, p<0.01). Among patients treated with statins, the high-intensity treatment group was associated with a reduction in all cause-mortality by 36% (HR: 0.64, 95% CI: 0.54-0.74, p<0.01) compared to patients treated with low intensity statins. Conclusions: Statin treatment among patients with PAD was associated with a statistically significant reduction in all-cause mortality, cardiovascular mortality, MACE, risk for amputation, or loss of patency. Higher statin dose seems to be associated with improved outcomes.

The prognostic value of initial serum lactate for survival in postcardiac arrest patients undergoing cardiac catheterization.

OBJECTIVES: We sought to investigate the prognostic value of serum lactate on survival in patients postcardiac arrest. BACKGROUND: Patients who experience cardiac arrest, in- or out-of-hospital, may have a poor outcome. Initial electrocardiograms may suggest ischemia as an underlying cause and urgent referral for catheterization occurs. It remains unclear which of these patients may suffer a poor outcome. METHODS: We retrospectively reviewed all patients at our institution taken for urgent catheterization after cardiac arrest between January 2014 and September 2018. Three hundred and eighty four patients were referred urgently to the cath lab during this period, 50 with prior arrest. RESULTS: Sixty six percent underwent coronary intervention. The mean age of the entire cohort was 57 years. Thirty four percent were female, 40% had a history of coronary artery disease, and 94% were intubated at the time of cardiac catheterization. Overall survival to discharge was 40%. Survival in patients who underwent coronary intervention compared with those who did not was similar (45.5 vs. 29.4%, p = .27). Mean lactate level in survivors versus nonsurvivors was 4.7 ± 3.8 and 9.8 ± 4.7 mmol/L, respectively (p < .05). When divided into tertiles by serum lactate (< 4.5, 4.5-9, 9 mmol/L), survival to discharge was 75, 29.4, and 17.6%, respectively (p < .05). Initial serum lactate and age were independent predictors of in-hospital mortality. CONCLUSIONS: In patients undergoing cardiac catheterization following cardiac arrest, routine measurement of serum lactate is a useful and available laboratory test that may help identify patients at risk for a poor outcome.

Vascular Imaging Before Transcatheter Aortic Valve Replacement (TAVR): Why and How?

Transcatheter aortic valve replacement (TAVR) has become an alternative to surgical intervention for symptomatic or severe aortic valve stenosis in patients with high surgical risk. Successful TAVR requires a multimodality imaging approach for appropriate patient selection and prosthesis sizing. Here, we describe individual imaging modalities and report their respective roles in this emerging field. To date, echocardiography remains the traditional test for determining patient candidacy and prosthesis selection, but computed tomography (CT) has been taking on an increasingly important role in the evaluation of both the aortic root anatomy and aortoiliofemoral vessels as a single examination. Cardiac magnetic resonance (CMR) is useful in grading the severity of aortic stenosis and should be considered a reasonable alternative to CT for the evaluation of the aortic annulus, e.g., when the administration of contrast media is contraindicated.

A Safety and Feasibility Single-Arm Study of a Novel Catheter Thrombectomy Device for the Treatment of Pulmonary Embolism (ENGULF).

Background: Despite advances in therapy options, pulmonary embolism (PE) continues to carry a high risk of mortality and morbidity. Currently, therapeutic options are limited with only 2 US Food and Drug Administration-cleared catheter-based embolectomy devices approved for the treatment of intermediate-risk PE. The novel Helo PE thrombectomy catheter (Endovascular Engineering, Inc) has a flexible and collapsible funnel with an internal agitator for a dual mechanism of treatment for acute PE. We sought to investigate the safety and feasibility of the novel Helo PE thrombectomy catheter in intermediate-risk PE. Methods: A prospective, single-arm feasibility study evaluating the Helo PE catheter was performed in patients presenting with intermediate-risk PE. Patients underwent preprocedural and postprocedural computed tomography angiography. Primary efficacy was the difference in preprocedural to postprocedural right ventricle/left ventricle (RV/LV) ratio. Primary and secondary safety outcomes were all-cause mortality, major life-threatening bleeding, device-related serious adverse events, pulmonary or cardiac injury, and clinical decompensation at 48 hours postprocedure and at 30 days. Results: A total of 25 patients from 8 centers were consented and included in the analysis. Preprocedural computed tomography angiography revealed an RV/LV ratio of 1.53 ± 0.27. All patients underwent a successful thrombectomy procedure. Postprocedure, the RV/LV ratio was reduced to 1.15 ± 0.18, translating into a 23.2 ± 12.81% decrease from baseline. No patients underwent adjunctive thrombolysis. Two patients had adjunctive catheter-directed embolectomy with an alternative device. Two patients had postprocedural anemia requiring transfusion but did not meet criteria for major life-threatening bleeding by VARC-2 criteria. There were no major adverse events including no deaths, major bleeding, pulmonary injury, or vascular complications at 48 hours or 30 days post procedure. Conclusions: In this multicenter first-in-human study, use of the Helo PE thrombectomy catheter was feasible and safe for the treatment of acute PE.

Relationship Between Pregnancy Complications and Subsequent Coronary Artery Disease Assessed by Coronary Computed Tomographic Angiography in Black Women.

BACKGROUND: Maternal pregnancy complications, particularly preeclampsia and gestational diabetes mellitus, are described to increase the risk for subsequent coronary artery disease (CAD). In addition, black women are at higher risk for CAD. The objective of this study was to compare the prevalence and extent of CAD as detected by coronary computed tomographic angiography (CCTA) in black women with and without a history of prior pregnancy complications. METHODS: We retrospectively evaluated patient characteristics and CCTA findings in groups of black women with a prior history of preterm delivery (n=154), preeclampsia (n=137), or gestational diabetes mellitus (n=148), and a matched control group of black women who gave birth without such complications (n=445). Univariate and multivariate analyses were performed to assess risk factors of CAD. RESULTS: All groups with prior pregnancy complications showed higher rates of any (≥20% luminal narrowing) and obstructive (≥50% luminal narrowing) CAD (preterm delivery: 29.2% and 9.1%; preeclampsia: 29.2% and 7.3%; and gestational diabetes mellitus: 47.3% and 15.5%) compared with control women (23.8% and 5.4%). After accounting for confounding factors at multivariate analysis, gestational diabetes mellitus remained a strong risk factor of any (odds ratio, 3.26; 95% CI, 2.03-5.22; P<0.001) and obstructive CAD (odds ratio, 3.00; 95% CI, 1.55-5.80; P<0.001) on CCTA. CONCLUSIONS: Black women with a history of pregnancy complications, particularly gestational diabetes mellitus, have a higher prevalence of CAD on CCTA while only a history of gestational diabetes mellitus was independently associated with any and obstructive CAD on CCTA.

Coronary CT angiography-derived quantitative markers for predicting in-stent restenosis.

OBJECTIVE: To evaluate quantitative markers derived from coronary CT angiography (coronary CTA) performed prior to percutaneous coronary intervention (PCI) with stent placement for predicting in-stent restenosis (ISR) as defined by quantitative coronary angiography (QCA). MATERIALS AND METHODS: We retrospectively analyzed the data of 74 patients (60 ± 12 years, 72% male) who had undergone dual-source coronary CTA within 3 months prior to a PCI procedure that included stent placement. Quantitative markers of the target vessel were derived from coronary CTA: Total plaque volume (TPV), calcified and non-calcified plaque volumes (CPV and NCPV), plaque burden (PB in %), remodeling index (RI), and lesion length (LL). Marker performance for predicting ISR, as defined by QCA at follow-up, was assessed. RESULTS: Twenty-one of 74 stented lesions showed ISR on follow-up (mean 616 ± 447 days). When comparing stent length and LL in patients with ISR, a trend towards less complete stent coverage of the target lesion was observed in cases with ISR (17/21 vs. 4/53 cases, p = 0.07). In multivariate analysis (corrected for dyslipidemia), the following markers showed predictive value for ISR (odds ratio [OR]): NCPV (OR 1.08, p = 0.045), LL (OR 1.38, p = 0.0024), and RI (OR 1.13, p = 0.0019). Sensitivity and specificity for ISR were: NCPV 65% and 80%, LL 74% and 74%, and RI 71% and 78%. At receiver-operating characteristics analysis, NCPV (0.72, p = 0.001), LL (0.77, p < 0.0001), and RI (0.79, p < 0.0001) showed discriminatory power for predicting ISR. A combination of these markers showed incremental predictive value (AUC 0.89, p < 0.0001) with sensitivity and specificity of 90% and 84%, respectively. CONCLUSION: Coronary CTA-derived NCPV, LL, and RI portend predictive value for ISR with incremental predictive value when combining these parameters.