Polymer free biolimus coated stents to treat acute ST-elevation myocardial infarction in Asian patients.

BACKGROUND: Patients undergoing primary percutaneous coronary intervention (PPCI) for ST-segment-elevation myocardial infarction (STEMI) have a high thrombotic burden and often have a high bleeding risk (HBR). Asian patients have different patterns of thrombotic and bleeding risk from other populations which may be particularly relevant in the setting of PPCI for STEMI. OBJECTIVES: To assess the safety and efficacy of the polymer free biolimus coated coronary stent (PF-BCS, BioFreedomTM, Biosensors International) in Asian STEMI patients. METHODS: Patients with acute STEMI who received at least one PF-BCS were invited to participate after their index procedure. Follow-up was performed at 1, 4, and 12 months. The primary endpoint was the rate of target lesion failure (TLF) at 1 year. A performance goal was derived from the biolimus eluting stent arm of the COMFORTABLE AMI study which was the only prior dedicated study of biolimus eluting stents in patients with STEMI. RESULTS: A total of 914 patients with STEMI were enrolled. Mean patient age was 60 ± 13 years, diabetes was present in 23.2% and 43% were active smokers. According to the ARC definition, 12.4% of the patients were HBR. TLF rate was 2.54% [95% CI: 1.52-3.56], p-value for non-inferiority <0.0001, p-value for superiority = 0.0004). The rate of definite/probable stent thrombosis was 0.44% [95% CI: 0.16-1.16]. There was a trend toward more BARC 3 to 5 bleeding in ARC-HBR patients (3.69% vs 1.46%, HR = 2.74, [95% CI: 0.87-8.62], p = 0.07). CONCLUSIONS: In Asian patients undergoing PPCI for STEMI and treated with variable durations of DAPT, the use of a PF-BCS was associated with low rates of TLF and stent thrombosis (NCT03609346).

Association of neighborhood gentrification and residential moves with hypertension and diabetes control in Los Angeles County, 2014-2019: A retrospective cohort study.

OBJECTIVE: To examine whether gentrification exposure is associated with future hypertension and diabetes control. METHODS: Linking records from an integrated health care system to census-tract characteristics, we identified adults with hypertension and/or diabetes residing in stably low-SES census tracts in 2014 (n = 69,524). We tested associations of census tract gentrification occurring between 2015 and 2019 with participants' disease control in 2019. Secondary analyses considered the role of residential moves (possible displacement), race and ethnicity, and age. RESULTS: Gentrification exposure was associated with improved odds of hypertension control (aOR: 1.08; 95% CI: 1.00, 1.17), especially among non-Hispanic Whites and adults >65 years. Gentrification was not associated with diabetes control overall, but control improved in the Hispanic subgroup. Disease control was similar regardless of residential moves in the overall sample, but disparate associations emerged in models stratified by race and ethnicity. CONCLUSIONS: Residents of newly gentrifying neighborhoods may experience modestly improved odds of hypertension and/or diabetes control, but associations may differ across population subgroups. POLICY IMPLICATIONS: Gentrification may support-or at least not harm-cardiometabolic health for some residents. City leaders and health systems could partner with impacted communities to ensure that neighborhood development meets the goals and health needs of all residents and does not exacerbate health disparities.

Association of Cost-Driven Residential Moves With Health-Related Outcomes Among California Renters.

Importance: Unaffordable housing is associated with adverse health-related outcomes, but little is known about the associations between moving due to unaffordable housing and health-related outcomes. Objective: To characterize the association of recent cost-driven residential moves with health-related outcomes. Design, Setting, and Participants: This cross-sectional study involved a weighted multivariable regression analysis of California Health Interview Survey data from January 1, 2011, to December 31, 2017. A population-based sample of 52 646 adult renters and other nonhomeowners in California were included. Data were analyzed from March 2, 2021, to January 6, 2023. Exposure: Cost-driven moves in the past 3 years relative to no move and to non-cost-driven moves. Main Outcomes and Measures: Five outcomes were assessed: psychological distress (low, moderate, or severe, as categorized by the 6-item Kessler Psychological Distress Scale), emergency department [ED] visits in the past year (any vs none), preventive care visits in the past year (any vs none), general health (poor or fair vs good, very good, or excellent), and walking for leisure in the past 7 days (in minutes). Results: Among 52 646 adult renters and other nonhomeowners, 50.3% were female, 85.2% were younger than 60 years, 45.3% were Hispanic, and 55.1% had income lower than 200% of the federal poverty level. Overall, 8.9% of renters reported making a recent cost-driven move, with higher prevalence among Hispanic (9.9%) and non-Hispanic Black (11.3%) renters compared with non-Hispanic White renters (7.2%). In multivariable models, compared with not moving, cost-driven moving was associated with a 4.2 (95% CI, 2.6-5.7) percentage point higher probability of experiencing moderate psychological distress; a 3.2 (95% CI, 1.9-4.5) percentage point higher probability of experiencing severe psychological distress; a 2.5 (95% CI, 0-4.9) percentage point higher probability of ED visits; a 5.1 (95% CI, 1.6-8.6) percentage point lower probability of having preventive care visits; a 3.7 (95% CI, 1.2-6.2) percentage point lower probability of having good, very good, or excellent general health; and 16.8 (95% CI, 6.9-26.6) fewer minutes of walking for leisure. General health, psychological distress, and walking for leisure were also worse with cost-driven moves relative to non-cost-driven moves, with a 3.2 (95% CI, 1.7-4.7) percentage point higher probability of experiencing moderate psychological distress; a 2.5 (95% CI, 1.2-3.9) percentage point higher probability of experiencing severe psychological distress; a 4.6 (95% CI, 2.1-7.2) percentage point lower probability of having good, very good, or excellent general health; and 13.0 (95% CI, 4.0-21.9) fewer minutes of walking for leisure. However, the incidence of preventive care and ED visits did not differ between those who made cost-driven vs non-cost-driven moves. Conclusions and Relevance: In this study, cost-driven moves were associated with adverse health-related outcomes relative to not moving and to non-cost-driven moves. These findings suggest that policies to improve housing affordability, prevent displacement, and increase access to health care for groups vulnerable to cost-driven moves may have the potential to improve population health equity, especially during the current national housing affordability crisis.

Abbreviated Antiplatelet Therapy After Coronary Stenting in Patients With Myocardial Infarction at High Bleeding Risk.

BACKGROUND: The optimal duration of antiplatelet therapy (APT) after coronary stenting in patients at high bleeding risk (HBR) presenting with an acute coronary syndrome remains unclear. OBJECTIVES: The objective of this study was to investigate the safety and efficacy of an abbreviated APT regimen after coronary stenting in an HBR population presenting with acute or recent myocardial infarction. METHODS: In the MASTER DAPT trial, 4,579 patients at HBR were randomized after 1 month of dual APT (DAPT) to abbreviated (DAPT stopped and 11 months single APT or 5 months in patients with oral anticoagulants) or nonabbreviated APT (DAPT for minimum 3 months) strategies. Randomization was stratified by acute or recent myocardial infarction at index procedure. Coprimary outcomes at 335 days after randomization were net adverse clinical outcomes events (NACE); major adverse cardiac and cerebral events (MACCE); and type 2, 3, or 5 Bleeding Academic Research Consortium bleeding. RESULTS: NACE and MACCE did not differ with abbreviated vs nonabbreviated APT regimens in patients with an acute or recent myocardial infarction (n = 1,780; HR: 0.83; 95% CI: 0.61-1.12 and HR: 0.86; 95% CI: 0.62-1.19, respectively) or without an acute or recent myocardial infarction (n = 2,799; HR: 1.03; 95% CI: 0.77-1.38 and HR: 1.13; 95% CI: 0.80-1.59; Pinteraction = 0.31 and 0.25, respectively). Bleeding Academic Research Consortium 2, 3, or 5 bleeding was significantly reduced in patients with or without an acute or recent myocardial infarction (HR: 0.65; 95% CI: 0.46-0.91 and HR: 0.71; 95% CI: 0.54-0.92; Pinteraction = 0.72) with abbreviated APT. CONCLUSIONS: A 1-month DAPT strategy in patients with HBR presenting with an acute or recent myocardial infarction results in similar NACE and MACCE rates and reduces bleedings compared with a nonabbreviated DAPT strategy. (Management of High Bleeding Risk Patients Post Bioresorbable Polymer Coated Stent Implantation With an Abbreviated Versus Prolonged DAPT Regimen [MASTER DAPT]; NCT03023020).

Racial and ethnic disparities in who receives unemployment benefits during COVID-19.

The impact of COVID-19 on job displacement in the United States has been unevenly experienced by race, ethnicity, and the socioeconomically disadvantaged. Although unemployment benefits may mitigate the effects of job displacement, this social safety net is also unevenly distributed across workers. We examine racial/ethnic differences in receiving unemployment benefits among workers displaced by the pandemic. We use data from the US Census Household Pulse Survey (HPS), which is specifically designed to capture the real time effects of the pandemic across a wide spectrum of social issues. (US Census, 2020) Unlike the Current Population Survey (CPS) data used in the monthly unemployment rate calculations, the HPS data allow us to identify workers directly displaced from their jobs by the pandemic. We analyze over 1.3 million HPS interviews from the first stage of the pandemic when the disruptions to the labor market were the most severe, covering the period from June 11, 2020 to December 22, 2020. We contribute to the literature on the labor market effects of the pandemic in two ways. One, the HPS data allow us to identify workers who directly experienced job loss as a result of the disruptions created by COVID-19 and to determine who did not receive unemployment insurance. Two, we present both bivariate and multivariate analyses to examine racial/ethnic disparities for five groups: non-Hispanic whites, Blacks, Hispanic, Asian, and non-Hispanic Other workers. We find that Black and Hispanic workers are more likely to be unemployed without Unemployment Insurance (UI). Black workers are 12.0% of the employed but 17.5% of displaced workers without UI. Hispanic workers are even more affected. Hispanic workers are 15.6% of the employed, but are 23.4% of all displaced workers without UI. Although there are limitations to using the HPS data-the survey was administered online in only English and Spanish and occupational and industry data are not available for displaced workers, the results still provide valuable insights informing the current policy debate about the effects of expanding UI.

Case report: A novel application of the MicroVascular Plug (MVP) in treating distal coronary perforation.

Coronary artery perforation during percutaneous coronary intervention (PCI) is a rare but severe complication which has been associated with a high rate of major adverse outcomes and is potentially fatal. We report a case of a 70-year-old male who presented with an anterior ST-elevation myocardial infarction. Coronary angiogram revealed a proximal left anterior descending (LAD) artery occlusion. Successful PCI was performed with stenting of the LAD. However, subsequent attempts to retrieve a jailed diagonal branch inadvertently led to distal coronary perforation of the LAD. After failed attempts to tamponade the perforation with prolonged balloon inflation, this was successfully sealed with the MicroVascular Plug (Medtronic) system. To our knowledge, this is the first reported case of such an application in the coronary system. This may prove to be a viable alternative in closure of distal coronary perforations.

How to set up regional STEMI networks: a "Stent - Save a life!" initiative.

Clinical guidelines recommend the development of ST-elevation myocardial infarction (STEMI) networks at community, regional and/or national level to ideally offer primary coronary angioplasty, or at least the best available STEMI care to all patients. However, there is a discrepancy between this clinical recommendation and daily practice, with no coordinated care for STEMI patients in many regions of the world. While this can be a consequence of lack of resources, in reality it is more frequently a lack of organisational power. In this paper, the Stent - Save a Life! Initiative (www.stentsavealife.com) proposes a practical methodology to set up a STEMI network effectively in any region of the world with existing resources, and to develop the STEMI network continuously once it has been established.

Common elements of service delivery models that optimise quality of life and health service use among older people with advanced progressive conditions: a tertiary systematic review.

INTRODUCTION: Health and social care services worldwide need to support ageing populations to live well with advanced progressive conditions while adapting to functional decline and finitude. We aimed to identify and map common elements of effective geriatric and palliative care services and consider their scalability and generalisability to high, middle and low-income countries. METHODS: Tertiary systematic review (Cochrane Database of Systematic Reviews, CINAHL, Embase, January 2000-October 2019) of studies in geriatric or palliative care that demonstrated improved quality of life and/or health service use outcomes among older people with advanced progressive conditions. Using frameworks for health system analysis, service elements were identified. We used a staged, iterative process to develop a 'common components' logic model and consulted experts in geriatric or palliative care from high, middle and low-income countries on its scalability. RESULTS: 78 studies (59 geriatric and 19 palliative) spanning all WHO regions were included. Data were available from 17 739 participants. Nearly half the studies recruited patients with heart failure (n=36) and one-third recruited patients with mixed diagnoses (n=26). Common service elements (≥80% of studies) included collaborative working, ongoing assessment, active patient participation, patient/family education and patient self-management. Effective services incorporated patient engagement, patient goal-driven care and the centrality of patient needs. Stakeholders (n=20) emphasised that wider implementation of such services would require access to skilled, multidisciplinary teams with sufficient resource to meet patients' needs. Identified barriers to scalability included the political and societal will to invest in and prioritise palliative and geriatric care for older people, alongside geographical and socioeconomic factors. CONCLUSION: Our logic model combines elements of effective services to achieve optimal quality of life and health service use among older people with advanced progressive conditions. The model transcends current best practice in geriatric and palliative care and applies across the care continuum, from prevention of functional decline to end-of-life care. PROSPERO REGISTRATION NUMBER: CRD42020150252.

Non-ST elevation myocardial infarction in pregnancy-a critical review of current evidence and guidelines.

Treatment for acute coronary syndrome (ACS) in women during pregnancy is challenging. Current standard treatment for ACS includes coronary angioplasty with guideline-directed medical therapy including aspirin, P2Y12 inhibitors, beta-blockers, angiotensin converting enzyme inhibitors, which may portend adverse effects to the fetus. ACS increases ischemic and obstetric complications during pregnancy and the postpartum period. Management of these patients necessitates balancing the potential risks and benefits to both maternal and fetal health. We present a case of a 37-year-old female with a background of hypertension and hyperlipidemia who presented with Non-ST segment elevation myocardial infarction (NSTEMI). The urine pregnancy test that was performed turned positive with an estimated gestational age of four weeks. After counselling on the potential risks and benefits, a diagnostic angiogram was performed which revealed triple vessel disease with critical stenosis in all three vessels. Percutaneous coronary intervention (PCI) was performed successfully with precautions taken to minimize radiation exposure to the fetus. In such cases, there is a fundamental trade-off between maternal and fetal health in the treatment of NSTEMI. Medications used for the treatment of acute coronary syndrome will need to be balanced against the potential risks to the fetus. Invasive coronary angiogram results in exposure to potentially teratogenic ionizing radiation and hence all efforts must be made to minimize exposure. Thus, risks and benefits of treatment ought to be discussed with patients and measures need to be taken to minimize potential harm to both the mother and fetus.

2021 Asian Pacific Society of Cardiology Consensus Recommendations on the Use of P2Y12 Receptor Antagonists in the Asia-Pacific Region: Special Populations.

Advanced age, diabetes, and chronic kidney disease not only increase the risk for ischaemic events in chronic coronary syndromes (CCS) but also confer a high bleeding risk during antiplatelet therapy. These special populations may warrant modification of therapy, especially among Asians, who have displayed characteristics that are clinically distinct from Western patients. Previous guidance has been provided regarding the classification of high-risk CCS and the use of newer-generation P2Y12 inhibitors (i.e. ticagrelor and prasugrel) after acute coronary syndromes (ACS) in Asia. The authors summarise evidence on the use of these P2Y12 inhibitors during the transition from ACS to CCS and among special populations. Specifically, they present recommendations on the roles of standard dual antiplatelet therapy, shortened dual antiplatelet therapy and single antiplatelet therapy among patients with coronary artery disease, who are either transitioning from ACS to CCS; elderly; or with chronic kidney disease, diabetes, multivessel coronary artery disease and bleeding events during therapy.

Abbreviated Antiplatelet Therapy in Patients at High Bleeding Risk With or Without Oral Anticoagulant Therapy After Coronary Stenting: An Open-Label, Randomized, Controlled Trial.

BACKGROUND: The optimal duration of antiplatelet therapy (APT) in patients at high bleeding risk with or without oral anticoagulation (OAC) after coronary stenting remains unclear. METHODS: In the investigator-initiated, randomize, open-label MASTER DAPT trial (Management of High Bleeding Risk Patients Post Bioresorbable Polymer Coated Stent Implantation With an Abbreviated Versus Standard DAPT Regimen), 4579 patients at high bleeding risk were randomized after 1-month dual APT to abbreviated or nonabbreviated APT strategies. Randomization was stratified by concomitant OAC indication. In this subgroup analysis, we report outcomes of populations with or without an OAC indication. In the population with an OAC indication, patients changed immediately to single APT for 5 months (abbreviated regimen) or continued ≥2 months of dual APT and single APT thereafter (nonabbreviated regimen). Patients without an OAC indication changed to single APT for 11 months (abbreviated regimen) or continued ≥5 months of dual APT and single APT thereafter (nonabbreviated regimen). Coprimary outcomes at 335 days after randomization were net adverse clinical outcomes (composite of all-cause death, myocardial infarction, stroke, and Bleeding Academic Research Consortium 3 or 5 bleeding events); major adverse cardiac and cerebral events (all-cause death, myocardial infarction, and stroke); and type 2, 3, or 5 Bleeding Academic Research Consortium bleeding. RESULTS: Net adverse clinical outcomes or major adverse cardiac and cerebral events did not differ with abbreviated versus nonabbreviated APT regimens in patients with OAC indication (n=1666; hazard ratio [HR], 0.83 [95% CI, 0.60-1.15]; and HR, 0.88 [95% CI, 0.60-1.30], respectively) or without OAC indication (n=2913; HR, 1.01 [95% CI, 0.77-1.33]; or HR, 1.06 [95% CI, 0.79-1.44]; Pinteraction=0.35 and 0.45, respectively). Bleeding Academic Research Consortium 2, 3, or 5 bleeding did not significantly differ in patients with OAC indication (HR, 0.83 [95% CI, 0.62-1.12]) but was lower with abbreviated APT in patients without OAC indication (HR, 0.55 [95% CI, 0.41-0.74]; Pinteraction=0.057). The difference in bleeding in patients without OAC indication was driven mainly by a reduction in Bleeding Academic Research Consortium 2 bleedings (HR, 0.48 [95% CI, 0.33-0.69]; Pinteraction=0.021). CONCLUSIONS: Rates of net adverse clinical outcomes and major adverse cardiac and cerebral events did not differ with abbreviated APT in patients with high bleeding risk with or without an OAC indication and resulted in lower bleeding rates in patients without an OAC indication. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT03023020.

Dual Antiplatelet Therapy after PCI in Patients at High Bleeding Risk.

BACKGROUND: The appropriate duration of dual antiplatelet therapy in patients at high risk for bleeding after the implantation of a drug-eluting coronary stent remains unclear. METHODS: One month after they had undergone implantation of a biodegradable-polymer sirolimus-eluting coronary stent, we randomly assigned patients at high bleeding risk to discontinue dual antiplatelet therapy immediately (abbreviated therapy) or to continue it for at least 2 additional months (standard therapy). The three ranked primary outcomes were net adverse clinical events (a composite of death from any cause, myocardial infarction, stroke, or major bleeding), major adverse cardiac or cerebral events (a composite of death from any cause, myocardial infarction, or stroke), and major or clinically relevant nonmajor bleeding; cumulative incidences were assessed at 335 days. The first two outcomes were assessed for noninferiority in the per-protocol population, and the third outcome for superiority in the intention-to-treat population. RESULTS: Among the 4434 patients in the per-protocol population, net adverse clinical events occurred in 165 patients (7.5%) in the abbreviated-therapy group and in 172 (7.7%) in the standard-therapy group (difference, -0.23 percentage points; 95% confidence interval [CI], -1.80 to 1.33; P<0.001 for noninferiority). A total of 133 patients (6.1%) in the abbreviated-therapy group and 132 patients (5.9%) in the standard-therapy group had a major adverse cardiac or cerebral event (difference, 0.11 percentage points; 95% CI, -1.29 to 1.51; P = 0.001 for noninferiority). Among the 4579 patients in the intention-to-treat population, major or clinically relevant nonmajor bleeding occurred in 148 patients (6.5%) in the abbreviated-therapy group and in 211 (9.4%) in the standard-therapy group (difference, -2.82 percentage points; 95% CI, -4.40 to -1.24; P<0.001 for superiority). CONCLUSIONS: One month of dual antiplatelet therapy was noninferior to the continuation of therapy for at least 2 additional months with regard to the occurrence of net adverse clinical events and major adverse cardiac or cerebral events; abbreviated therapy also resulted in a lower incidence of major or clinically relevant nonmajor bleeding. (Funded by Terumo; MASTER DAPT ClinicalTrials.gov number, NCT03023020.).

COVID-19 Medical Vulnerability Indicators: A Predictive, Local Data Model for Equity in Public Health Decision Making.

This article reports the outcome of a project to develop and assess a predictive model of vulnerability indicators for COVID-19 infection in Los Angeles County. Multiple data sources were used to construct four indicators for zip code tabulation areas: (1) pre-existing health condition, (2) barriers to accessing health care, (3) built environment risk, and (4) the CDC's social vulnerability. The assessment of the indicators finds that the most vulnerable neighborhoods are characterized by significant clustering of racial minorities. An overwhelming 73% of Blacks reside in the neighborhoods with the two highest levels of pre-existing health conditions. For the barriers to accessing health care indicator, 40% of Latinx reside in the highest vulnerability places. The built environment indicator finds that selected Asian ethnic groups (63%), Latinx (55%), and Blacks (53%) reside in the neighborhoods designated as high or the highest vulnerability. The social vulnerability indicator finds 42% of Blacks and Latinx and 38% of selected Asian ethnic group residing in neighborhoods of high vulnerability. The vulnerability indicators can be adopted nationally to respond to COVID-19. The metrics can be utilized in data-driven decision making of re-openings or resource distribution such as testing, vaccine distribution and other pandemic-related resources to ensure equity for the most vulnerable.

Community-Integrated Intermediary Care (CIIC) Service Model to Enhance Family-Based, Long-Term Care for Older People: Protocol for a Cluster Randomized Controlled Trial in Thailand.

BACKGROUND: Thailand is one of the most rapidly aging countries in Asia. Traditional family-based care, which has been the basis of most care for older people, is becoming unsustainable as families become smaller. In addition, women tend to be adversely affected as they still form the bulk of caregivers for older people, and many are likely to exit the labor market in order to provide care. Many family caregivers also have no or minimal training, and they may be called upon to provide quite complex care, increasing the proportion of older people receiving suboptimal care if they rely only on informal care that is provided by families and friends. Facing the increasing burden of noncommunicable diseases and age-related morbidity, Thai communities are increasingly in need of community-integrated care models for older persons that can link existing health systems and reduce the burden upon caring families. This need is common to many countries in the Association of Southeast Asian Nations (ASEAN). OBJECTIVE: In this study, we aimed to assess the effectiveness of a community-integrated intermediary care (CIIC) model to enhance family-based care for older people. METHODS: This paper describes a cluster randomized controlled trial comprised of 6 intervention clusters and 6 control clusters that aim to recruit 2000 participants in each arm. This research protocol has been approved by the World Health Organization Ethics Review Committee. The intervention clusters will receive an integrated model of care structured around (1) a community respite service, (2) the strengthening of family care capacity, and (3) an exercise program that aims to prevent entry into long-term care for older people. Control group clusters receive usual care (ie, the current system of long-term care common to all provinces in Thailand), consisting principally of a volunteer-assisted home care service. The trial will be conducted over a period of 2 years. The primary outcome is family caregiver burden measured at a 6-month follow-up, as measured by the Caregiver Burden Inventory. Secondary outcomes consist of biopsychosocial indicators including functional ability, as measured using an activity of daily living scale; depression, as measured by the Geriatric Depression Scale; and quality of life of older people, as measured by the EuroQol 5-dimensions 5-levels scale. Intention-to-treat analysis will be followed. RESULTS: The CIIC facility has been established. Community care prevention programs have been launched at the intervention clusters. Family caregivers are receiving training and assistance. However, the COVID-19 pandemic delayed the intervention. CONCLUSIONS: Since ASEAN and many Asian countries share similar traditional family-based, long-term care systems, the proposed CIIC model and the protocol for its implementation and evaluation may benefit other countries wishing to adopt similar community-integrated care models for older people at risk of needing long-term care. TRIAL REGISTRATION: Thai Clinical Trials Registry TCTR20190412004; http://www.thaiclinicaltrials.org/. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/20196.

Predicting 2-year all-cause mortality after contemporary PCI: Updating the logistic clinical SYNTAX score.

AIMS: We aimed to update the logistic clinical SYNTAX score to predict 2 year all-cause mortality after contemporary percutaneous coronary intervention (PCI). METHODS AND RESULTS: We analyzed 15,883 patients in the GLOBAL LEADERS study who underwent PCI. The logistic clinical SYNTAX model was updated after imputing missing values by refitting the original model (refitted original model) and fitting an extended new model (new model, with, selection based on the Akaike Information Criterion). External validation was performed in 10,100 patients having PCI at Fu Wai hospital. Chronic obstructive pulmonary disease, prior stroke, current smoker, hemoglobin level, and white blood cell count were identified as additional independent predictors of 2 year all-cause mortality and included into the new model. The c-indexes of the original, refitted original and the new model in the derivation cohort were 0.74 (95% CI 0.72-0.76), 0.75 (95% CI 0.73-0.77), and 0.78 (95% CI 0.76-0.80), respectively. The c-index of the new model was lower in the validation cohort than in the derivation cohort, but still showed improved discriminative ability of the newly developed model (0.72; 95% CI 0.67-0.77) compared to the refitted original model (0.69; 95% CI 0.64-0.74). The models overestimated the observed 2 year all-cause mortality of 1.11% in the Chinese external validation cohort by 0.54 percentage points, indicating the need for calibration of the model to the Chinese patient population. CONCLUSIONS: The new model of the logistic clinical SYNTAX score better predicts 2 year all-cause mortality after PCI than the original model. The new model could guide clinical decision making by risk stratifying patients undergoing PCI.

High-Risk "Protected" Percutaneous Coronary Intervention with Mechanical Circulatory Support in a Non-Surgical Center - An Early Asian Experience.

High-risk "protected" percutaneous coronary intervention (PCI) using mechanical circulatory support (MCS) devices, particularly the Impella axial pump, has emerged as a viable treatment option for high-risk patients with satisfactory clinical outcomes. High-risk and complex interventions have mostly remained within the domain of surgical centers. We report on an early "protected" PCI experience using MCS with the Impella flow pump at a high-volume PCI hospital without on-site surgery. A total of 5 patients underwent elective "protected" PCI utilizing MCS with Impella at our institution. The mean left ventricular ejection fraction was 28 ± 10% and all patients had triple vessel coronary artery disease with the majority having a high SYNTAX score. Device implantation and procedural success were achieved in all cases with no intraprocedural or access site complications. All patients were alive at 30 days and clinically well. The Impella unloads the ventricle, improves forward cardiac output and lowers myocardial oxygen demand, thereby improving mean arterial pressure and coronary perfusion. Device insertion is relatively quick and the "learning curve" is short, centering mainly around managing large bore access. Our limited experience suggests that not only is high-risk PCI with Impella support feasible in a non-surgical center, but that it may be crucial to enable success.

Drug-Coated Balloons for Coronary Artery Disease: Third Report of the International DCB Consensus Group.

Although drug-eluting stents are still the default interventional treatment of coronary artery disease, drug-coated balloons (DCBs) represent a novel alternative therapeutic strategy in certain anatomic conditions. The effect of DCBs is based on the fast and homogenous transfer of antiproliferative drugs into the vessel wall during single balloon inflation by means of a lipophilic matrix without the use of permanent implants. Although their use is established for in-stent restenosis of both bare-metal and drug-eluting stents, recent randomized clinical data demonstrate a good efficacy and safety profile in de novo small-vessel disease and high bleeding risk. In addition, there are other emerging indications (e.g., bifurcation lesions, large-vessel disease, diabetes mellitus, acute coronary syndromes). Because the interaction among the different delivery balloon designs, doses, formulations, and release kinetics of the drugs used is important, there seems to be no "class effect" of DCBs. On the basis of the amount of recently published data, the International DCB Consensus Group provides this update of previous recommendations summarizing the historical background, technical considerations such as choice of device and implantation technique, possible indications, and future perspectives.

Sleep apnoea and cardiovascular outcomes after coronary artery bypass grafting.

OBJECTIVE: Patients with advanced coronary artery disease are referred for coronary artery bypass grafting (CABG) and it remains unknown if sleep apnoea is a risk marker. We evaluated the association between sleep apnoea and major adverse cardiac and cerebrovascular events (MACCE) in patients undergoing non-emergent CABG. METHODS: This was a prospective cohort study conducted between November 2013 and December 2018. Patients from four public hospitals referred to a tertiary cardiac centre for non-emergent CABG were recruited for an overnight sleep study using a wrist-worn Watch-PAT 200 device prior to CABG. RESULTS: Among the 1007 patients who completed the study, sleep apnoea (defined as apnoea-hypopnoea index ≥15 events per hour) was diagnosed in 513 patients (50.9%). Over a mean follow-up period of 2.1 years, 124 patients experienced the four-component MACCE (2-year cumulative incidence estimate, 11.3%). There was a total of 33 cardiac deaths (2.5%), 42 non-fatal myocardial infarctions (3.7%), 50 non-fatal strokes (4.9%) and 36 unplanned revascularisations (3.2%). The crude incidence of MACCE was higher in the sleep apnoea group than the non-sleep apnoea group (2-year estimate, 14.7% vs 7.8%; p=0.002). Sleep apnoea predicted the incidence of MACCE in unadjusted Cox regression analysis (HR 1.69; 95% CI 1.18 to 2.43), and remained statistically significant (adjusted HR 1.57; 95% CI 1.09 to 2.25), after adjustment for age, sex, body mass index, left ventricular ejection fraction, diabetes mellitus, hypertension, chronic kidney disease and excessive daytime sleepiness. CONCLUSION: Sleep apnoea is independently associated with increased MACCE in patients undergoing CABG. TRIAL REGISTRATION NUMBER: NCT02701504.

Other considerations than: how much will universal health coverage cost?

Globally, countries have agreed to pursue the progressive realization of universal health coverage (UHC) and there is now a high level of political commitment to providing universal coverage of essential health services while ensuring that individuals are financially protected against high health spending. The aim of this paper is to help policy-makers think through the progressive realization of UHC. First, the pitfalls of applying global normative expenditure targets in estimating the national revenue required for UHC are discussed. Then, several recommendations on estimating national revenue are made by moving beyond the question of how much UHC will cost and focusing instead on the national health-care reforms and policy choices needed to progress towards UHC. In particular, costing exercises are recommended as a tool for comparing different service delivery options and investment in data infrastructure is recommended for improving the information needed to identify the best policies. These recommendations are intended to assist health policy-makers and international and national agencies who are developing country plans for the progressive realization of UHC.

À l'échelle mondiale, les pays sont convenus de poursuivre la réalisation progressive de la couverture sanitaire universelle, et l'on observe désormais un fort niveau d'engagement politique en faveur de la couverture universelle des services de santé essentiels en veillant à ce que les individus soient financièrement à l'abri de toute dépense de santé élevée. L'objectif de cet article est d'aider les responsables politiques à effectuer un examen minutieux en vue de la réalisation progressive de la couverture sanitaire universelle. Pour commencer, nous examinons les écueils liés à l'application d'objectifs de dépenses normatifs mondiaux au moment d'estimer le revenu national requis pour la couverture sanitaire universelle. Nous formulons ensuite plusieurs recommandations concernant l'estimation du revenu national, en dépassant la question du coût de la couverture sanitaire universelle pour nous concentrer sur les réformes nationales en matière de soins de santé et sur les choix politiques nécessaires pour faire progresser la couverture sanitaire universelle. Nous recommandons notamment de procéder à des exercices d'établissement des coûts pour comparer différentes options de prestation de services et d'investir dans des infrastructures de données pour améliorer les informations nécessaires à l'identification des meilleures politiques. Ces recommandations visent à aider les responsables des politiques de santé et les organismes internationaux et nationaux qui élaborent des plans nationaux pour la réalisation progressive de la couverture sanitaire universelle.

A nivel mundial, los países han acordado procurar la realización progresiva de la cobertura sanitaria universal (universal health coverage, UHC) y ahora existe un alto nivel de compromiso político para proporcionar una cobertura universal de los servicios sanitarios esenciales, al tiempo que se garantiza la protección financiera de las personas frente a los elevados gastos sanitarios. El objetivo de este documento es ayudar a los responsables de formular políticas a pensar en la realización progresiva de la UHC. Primero, se discuten las trampas en la aplicación de las metas globales de gastos normativos al estimar los ingresos nacionales requeridos para la UHC. Luego, se hacen varias recomendaciones sobre la estimación de los ingresos nacionales al ir más allá de la cuestión de cuánto costará la UHC y enfocarse en cambio en las reformas nacionales de salud y en las opciones de políticas necesarias para progresar hacia la UHC. En particular, se recomiendan ejercicios de cálculo de costos como herramienta para comparar diferentes opciones de prestación de servicios y se recomienda invertir en infraestructura de datos para mejorar la información necesaria con el fin de identificar las mejores políticas. Estas recomendaciones tienen por objeto ayudar a los responsables de formular políticas de salud y a los organismos internacionales y nacionales que están elaborando planes nacionales para la realización progresiva de la UHC.