Coronary artery bypass grafting in octogenarians: a nomogram for predicting all-cause mortality.

BACKGROUND: The benefits and risks of coronary artery bypass grafting (CABG) in octogenarians remain unclear. This study aimed to identify the predictors of increased risk of all-cause mortality in octogenarian patients after CABG. METHODS: We retrospectively analyzed the data of 1636 octogenarians who underwent isolated elective on-pump CABG between 2007 and 2016. The primary endpoint was mortality from any cause. The Kaplan-Meier curve was generated for mortality. A univariate Cox regression was performed for preprocedural and procedural variables. The Akaike information criterion (AIC) using the Cox proportional hazard model was applied to determine the strongest predictors. We designed a nomogram based on the selected variables to calculate the mortality risk after one, five, and ten years. The bootstrap resampling based on the C-index was performed to validate the final model. Calibration plots were created at different time points. RESULTS: The mean age of the patients was 82.03 years (SD = 1.74), and 74% were male. In a median follow-up of 9.2 (95% CI 9.0,9.5) years, 626 (38.2%) patients died. After the selection of best predictors based on AIC, the multivariable Cox regression showed that ejection fraction < 40 (HR 1.41, 95% CI 1.21-1.65, P < 0.001), two-vessel disease (HR: 0.59, 95% CI 0.40-0.89, P = 0.012), peripheral vascular disease (HR 1.52, 95% CI 1.05-2.21, P = 0.027), and valvular heart disease (HR 1.45, 95% CI 1.24-1.69, P < 0.001) were the significant predictors of all-cause mortality. CONCLUSION: Octogenarians who undergo CABG have a high mortality risk, influenced by several preprocedural and procedural risk factors. The proposed nomogram can be considered for optimizing the management of this vulnerable age group. Clinical registration number IR.TUMS.THC.REC.1400.081.

Long-term outcomes of ischaemia with no obstructive coronary artery disease (INOCA): a systematic review and meta-analysis.

BACKGROUND: The prognosis of myocardial ischaemia with no obstructive coronary artery disease (INOCA) and its underlying vasomotor disorders, vasospastic angina (VSA) and microvascular angina (MVA), is not well defined. The aim of this study was to perform a systematic review and meta-analysis of studies evaluating the long-term prognosis of patients with INOCA. METHODS: We included studies evaluating the prognosis of patients with INOCA published between January 1984 and August 2023 in Medline, Embase, Web of Science and Cochrane databases. Studies were selected if they included patients who fulfilled the Coronary Vasomotor Disorders International Study Group (COVADIS) criteria for either possible or definitive VSA or MVA. The primary outcomes were composite of all-cause death and myocardial infarction (MI), and major adverse cardiovascular event (MACE) at annual intervals up to 5-year follow-up. The incidence of primary outcomes for INOCA, each INOCA endotype and by method used to determine the diagnosis was calculated using the random effects model. RESULTS: Fifty-four studies (17 302 patients) meeting the eligibility criteria were selected. The rate of all-cause death and MI with VSA was 0.7 (95% CI 0.4 to 1.0)/100 patient-years and with MVA was 1.1 (95% CI 0.7 to 1.5)/100 patient-years (p>0.05). The rate of MACE with VSA was 1.1 (95% CI 0.5 to 1.9)/100 patient-years and with MVA was 2.5 (95% CI 1.6 to 3.6)/100 patient-years (p=0.025). Patients with reduced coronary flow reserve (CFR) had higher all-cause death and MI rates than patients whose diagnosis of MVA was established based on an abnormal exercise or imaging stress test (4.7 (95% CI 2.0 to 8.4) vs 0.5 (95% CI 0.1 to 1.1) vs 1.1 (95% CI 0.5 to 2.0)/100 patient-years, p=0.001). CONCLUSIONS: Overall, patients with INOCA have a low rate of MACEs, but patients with MVA, especially those with reduced CFR, have a significantly higher rate of MACE than other subgroups, although there is high heterogeneity among the included studies. PROSPERO REGISTRATION NUMBER: CRD42021275070.

Influence of Subclinical Atherosclerosis Burden and Progression on Mortality.

BACKGROUND: Atherosclerosis is a dynamic process. There is little evidence regarding whether quantification of atherosclerosis extent and progression, particularly in the carotid artery, in asymptomatic individuals predicts all-cause mortality. OBJECTIVES: This study sought to evaluate the independent predictive value (beyond cardiovascular risk factors) of subclinical atherosclerosis burden and progression and all-cause mortality. METHODS: A population of 5,716 asymptomatic U.S. adults (mean age 68.9 years, 56.7% female) enrolled between 2008 and 2009 in the BioImage (A Clinical Study of Burden of Atherosclerotic Disease in an At Risk Population) study underwent examination by vascular ultrasound to quantify carotid plaque burden (cPB) (the sum of right and left carotid plaque areas) and by computed tomography for coronary artery calcium (CAC). Follow-up carotid vascular ultrasound was performed on 732 participants a median of 8.9 years after the baseline exam. All participants were followed up for all-cause mortality, the primary outcome. Trend HRs are the per-tertile increase in each variable. RESULTS: Over a median 12.4 years' follow-up, 901 (16%) participants died. After adjustment for cardiovascular risk factors and background medication, baseline cPB and CAC score were both significantly associated with all-cause mortality (fully adjusted trend HR: 1.23; 95% CI: 1.16-1.32; and HR: 1.15; 95% CI: 1.08-1.23), respectively (both P < 0.001), thus providing additional prognostic value. cPB performed better than CAC score. In participants with a second vascular ultrasound evaluation, median cPB progressed from 29.2 to 91.3 mm3. cPB progression was significantly associated with all-cause mortality after adjusting for cardiovascular risk factors and baseline cPB (HR: 1.03; 95% CI: 1.01-1.04 per absolute 10-mm3 change; P = 0.01). CONCLUSIONS: Subclinical atherosclerosis burden (cPB and CAC) in asymptomatic individuals was independently associated with all-cause mortality. Moreover, atherosclerosis progression was independently associated with all-cause mortality.

The Impact of Body Mass Index on the Mortality of Myocardial Infarction Patients With Nonobstructive Coronary Arteries.

OBJECTIVES: Myocardial infarction without significant stenosis or occlusion of the coronary arteries carries a high risk of recurrent major adverse cardiovascular events and poor prognosis. This study aimed to investigate the association between body mass index and outcomes in patients with a suspected myocardial infarction with nonobstructive coronary artery disease (MINOCA). METHODS: Patients were recruited at Bergmannsheil University Hospital from January 2010 to April 2021. The primary outcomes were in-hospital and long-term mortality. Secondary outcomes consisted of adverse events during hospitalization and during follow-up. RESULTS: A total of 373 patients were included in the study, with a mean follow-up time of 6.2 years. The patients were divided into different BMI groups: < 25 kg/m² (n = 121), 25-30 kg/m² (n = 140), and > 30 kg/m² (n = 112). In-hospital mortality was 1.7% versus 2.1% versus 4.5% (p = 0.368). However, long-term mortality tended to be higher in the < 25 kg/m² group compared to the 25-30 and > 30 kg/m² groups (log-rank p = 0.067). Subgroup analysis using Kaplan-Meier analysis showed a higher rate of cardiac cause of death in the < 25 kg/m² group compared to the 25-30 and > 30 kg/m² groups: 5.7% versus 1.1% versus 0.0% (log-rank p = 0.042). No significant differences were observed in other adverse events between the different BMI groups during hospitalization and long-term follow-up. CONCLUSIONS: Patients with a BMI < 25 kg/m² who experience a suspected myocardial infarction without significant coronary artery disease may have higher all-cause mortality and cardiovascular cause of death. However, further data are needed to confirm these findings.

High-sensitivity C-reactive protein to high-density lipoprotein cholesterol ratio predicts long-term adverse outcomes in patients who underwent percutaneous coronary intervention: A prospective cohort study.

High-sensitivity C-reactive protein (hsCRP) to high-density lipoprotein cholesterol (HDL-C) ratio (CHR) is associated with coronary artery disease (CAD), but its predictive value for long-term adverse outcomes in patients with CAD following percutaneous coronary intervention (PCI) remains unexplored and is the subject of this study. Patients with CAD who underwent PCI at the Korea University Guro Hospital-Percutaneous Coronary Intervention (KUGH-PCI) Registry since 2004 were included. Patients were categorized into tertiles according to their CHR. The end points were all-cause mortality (ACM), cardiac mortality (CM) and major adverse cardiac events (MACEs). Kaplan-Meier analysis, multivariate Cox regression, restricted cubic spline (RCS) and sensitivity analyses were performed. A total of 3260 patients were included and divided into Group 1 (CHR <0.830, N = 1089), Group 2 (CHR = 0.830-3.782, N = 1085) and Group 3 (CHR >3.782, N = 1086). Higher CHR tertiles were associated with progressively greater risks of ACM, CM and MACEs (log-rank, p < 0.001). Multivariate Cox regression showed that patients in the highest tertile had greater risks of ACM (HR: 2.127 [1.452-3.117]), CM (HR: 3.575 [1.938-6.593]) and MACEs (HR: 1.337 [1.089-1.641]) than those in the lowest tertile. RCS analyses did not reveal a significant non-linear relationship between CHR and ACM, CM or MACEs. The significant associations remained significant in the sensitivity analyses, RCS analyses with or without extreme values, subgroup analyses and multiple imputations for missing data. Elevated CHR is a novel, independent risk factor for long-term ACM, CM and MACEs in CAD patients following PCI.

Sex differences in outcomes of patients undergoing on-pump coronary artery bypass grafting surgery.

There are controversies regarding the impact of sex on mortality and postoperative complications in patients undergoing on-pump coronary artery bypass grafting (CABG), although some studies demonstrate comparable outcomes. This study sought to evaluate sex differences regarding risk factors associated with hospital mortality and postoperative clinical outcomes among patients undergoing isolated on-pump CABG. We conducted a retrospective observational cohort study of patients who underwent isolated on-pump CABG from January 1996 to January 2020. Patients were divided into two groups (male and female) and compared regarding preoperative characteristics, surgical technical variables, and in-hospital outcomes. All-cause mortality between groups was compared using logistic regression. Risk factors for mortality, along with their respective odds ratios (OR), were separately assessed using a logistic regression model with p-values for interaction. We analyzed 4,882 patients, of whom 31.6% were female. Women exhibited a higher prevalence of age >75 years (12.2% vs 8.3%, p<0.001), obesity (22.6% vs 11.5%, p<0.001), diabetes (41.6% vs 32.2%, p<0.001), hypertension (85.2% vs 73.5%, p<0.001), and NYHA functional classes 3 and 4 (16.2% vs 11.2%, p<0.001) compared to men. Use of the mammary artery for revascularization was less frequent among women (73.8% vs 79.9%, p<0.001), who also received fewer saphenous vein grafts (2.17 vs 2.27, p = 0.002). A history of previous or recent myocardial infarction (MI) had an impact on women's mortality, unlike in men (OR 1.61 vs 0.94, p = 0.014; OR 1.86 vs 0.99, p = 0.015, respectively). After adjusting for several risk factors, mortality was found to be comparable between men and women, with an OR of 1.20 (95% CI 0.94-1.53, p = 0.129). In conclusion, female patients undergoing isolated on-pump CABG presented with a higher number of comorbidities. Previous and recent MI were associated with higher mortality only in women. In this cohort analysis, female gender was not identified as an independent risk factor for outcome after CABG.

Assessment of EuroSCORE II and STS Score Performance and the Impact of Surgical Urgency in Isolated Coronary Artery Bypass Graft Surgery at a Referral Center in São Paulo, Brazil.

INTRODUCTION: Risk prediction models, such as The Society of Thoracic Surgeons (STS) risk score and the European System for Cardiac Operative Risk Evaluation II (EuroSCORE II), are recommended for assessing operative mortality in coronary artery bypass grafting (CABG). However, their performance is questionable in Brazil. OBJECTIVE: To assess the performance of the STS score and EuroSCORE II in isolated CABG at a Brazilian reference center. METHODS: Observationaland prospective study including 438 patients undergoing isolated CABG from May 2022-May 2023 at the Instituto Dante Pazzanese de Cardiologia. Observed mortality was compared with predicted mortality (STS score and EuroSCORE II) by discrimination (area under the curve [AUC]) and calibration (observed/expected ratio [O/E]) in the total sample and subgroups of stable coronary artery disease (CAD) and acute coronary syndrome (ACS). RESULTS: Observed mortality was 4.3% (n=19) and estimated at 1.21% and 2.74% by STS and EuroSCORE II, respectively. STS (AUC=0.646; 95% confidence interva [CI] 0.760-0.532) and EuroSCORE II (AUC=0.697; 95% CI 0.802-0.593) presented poor discrimination. Calibration was absent for the North American mode (P<0.05) and reasonable for the European model (O/E=1.59, P=0.056). In the subgroups, EuroSCORE II had AUC of 0.616 (95% CI 0.752-0.480) and 0.826 (95% CI 0.991-0.661), while STS had AUC of 0.467 (95% CI 0.622-0.312) and 0.855 (95% CI 1.0-0.706) in ACS and CAD patients, respectively, demonstrating good score performance in stable patients. CONCLUSION: The predictive models did not perform optimally in the total sample, but the EuroSCORE was superior, especially in elective stable patients, where accuracy was satisfactory.

Myocardial contrast echocardiography evaluation of coronary microvascular dysfunction to Predict MACEs in patients with heart failure with preserved ejection fraction follow-up.

BACKGROUND: CMD refers to the abnormalities of the tiny arteries and capillaries within the coronary artery system, which result in restricted or abnormal blood flow. CMD is an important mechanism involved in ischemic heart disease and secondary heart failure. CMD can explain left ventricular dysfunction and poor prognosis.The European Association of Cardiovascular Imaging recommends the use of MCE for the assessment of myocardial perfusion. Myocardial contrast echocardiography (MCE) is used to evaluate the accuracy of Coronary microvascular dysfunction (CMD) for predicting major adverse cardiac events (MACEs) in patients with heart failure with preserved ejection fraction (HFpEF) at follow-up. METHODS: The clinical data of 142 patients diagnosed with HFpEF in our hospital from January 2020 to January 2022 were retrospectively summarized and stratified into 77 cases (> 1) in the CMD group and 65 cases (= 1) in the non-CMD group based on the perfusion score index (PSI) of the 17 segments of the left ventricle examined by the admission MCE, and the perfusion parameters were measured at the same time, including the peak plateau intensity (A value), the curve slope of the curve rise (ßvalue) and A × ß values. At a median follow-up of 27 months till October 2023, MACEs were recorded mainly including heart failure exacerbation, revascularization, cardiac death, etc. RESULTS: Increasing age, hypertension, diabetes, and coronary artery disease in the CMD group resulted in decreased left ventricular ejection fraction (LVEF), increased plasma NT-B-type natriuretic peptide (BNP) and left ventricular global longitudinal strain (LVGLS), decreased A-values and A × ß-values, and an increased incidence of MACEs (P < 0.05). Univariate and multivariate Cox regression analyses showed that LVGLS (HR = 1.714, 95% CI = 1.289-2.279, P < 0.001) and A × ß values (HR = 0.636, 95% CI = 0.417 to 0.969, P = 0.035) were independent predictors of MACEs in patients with HFpEF. The receiver operating characteristic curve (ROC) showed that the area under the curve (AUC) of LVGLS combined with A × ß value for diagnosis of MACEs was 0.861 (95% CI = 0.761 ~ 0.961, P < 0.001), which was significantly higher than that of LVGLS or A × ß value (P < 0.05). The Kaplan-Meier survival curves showed that the cumulative survival rate in CMD group was significantly lower than non-CMD group (logrank χ2 = 6.626, P = 0.010), with the most significant difference at 20 months of follow-up. CONCLUSION: MCE can evaluate CMD semi-quantitatively and quantitatively, LVGLS combined with A × ß value has good performance in predicting the risk of developing MACEs in patients with HFpEF at 3 years of follow-up, and CMD can be used as an important non-invasive indicator for assessing clinical prognosis.

The U -shape relationship between free fatty acid level and adverse outcomes in coronary artery disease patients with hypertension: evidence from a large prospective cohort study.

BACKGROUND: Evidence is scarce on the effect of free fatty acid (FFA) level in the prognosis of coronary artery disease (CAD) patients with hypertension. This study. METHODS: A large prospective cohort study with a follow-up period of average 2 years was conducted at Xinjiang Medical University Affiliated First Hospital from December 2016 to October 2021. A total of 10,395 CAD participants were divided into groups based on FFA concentration and hypertension status, and then primary outcome mortality and secondary endpoint ischemic events were assessed in the different groups. RESULTS: A total of 222 all-cause mortality (ACMs), 164 cardiac mortality (CMs), 718 major adverse cardiovascular events (MACEs) and 803 major adverse cardiovascular and cerebrovascular events (MACCEs) were recorded during follow-up period. A nonlinear relationship between FFA and adverse outcomes was observed only in CAD patients with hypertension. Namely, a "U -shape" relationship between FFA levels and long-term outcomes was found in CAD patients with hypertension. Lower FFA level (< 310 µmol/L), or higher FFA level (≥ 580 µmol/L) at baseline is independent risk factors for adverse outcomes. After adjustment for confounders, excess FFA increases mortality (ACM, HR = 1.957, 95%CI(1.240-3.087), P = 0.004; CM, HR = 2.704, 95%CI(1.495-4.890, P = 0.001) and MACE (HR = 1.411, 95%CI(1.077-1.848), P = 0.012), MACCE (HR = 1.299, 95%CI (1.013-1.666), P = 0.040) prevalence. Low levels of FFA at baseline can also increase the incidence of MACE (HR = 1.567,95%CI (1.187-2.069), P = 0.002) and MACCE (HR = 1.387, 95%CI (1.070-1.798), P = 0.013). CONCLUSIONS: Baseline FFA concentrations significantly associated with long-term mortality and ischemic events could be a better and novel risk biomarker for prognosis prediction in CAD patients with hypertension. TRIAL REGISTRATION: The details of the design were registered on https://www.chictr.org.cn/ (Identifier NCT05174143).

Intravascular imaging-guided versus angiography-guided percutaneous coronary intervention: a systematic review and bayesian network meta-analysis of randomized controlled trials.

BACKGROUND: Percutaneous coronary intervention (PCI) has become one of the most commonly performed interventional life-saving procedures worldwide. Intravascular Imaging (intravascular ultrasound (IVUS) and optical coherence tomography (OCT)) have initially evolved to guide PCI compared with angiography. However, this technology is not universally employed in all PCI procedures, and there is ongoing controversy regarding its additional benefits to patient outcomes. We aim to estimate the efficacy and safety of imaging modalities during PCI, allowing pre-, per, and post-intervention assessment of coronary vascularization. METHODS: A systematic review and Bayesian network meta-analysis of randomized controlled trials (RCTs), which were retrieved from PubMed, WOS, SCOPUS, EMBASE, and CENTRAL through September 2023. We used R, version 4.2.0. Effect sizes will be presented as odds ratios with accompanying 95% credible intervals. PROSPERO ID: CRD42024507821. RESULTS: Our study, encompassing 36 RCTs with a total of 17,572 patients, revelead that compared to conventional angiography, IVUS significantly reduced the risk of major adverse cardiovascular events (MACE) (OR: 0.71 [95% CrI: 0.56 to 0.87]) but not OCT (OR: 0.91 [95% CrI: 0.62 to 1.39]), IVUS and OCT significantly reduced the risk of cardiac death (OR: 0.50 [95% CrI: 0.33 to 0.76]) and (OR: 0.55 [95% CrI: 0.31 to 0.98]), respectively, IVUS significantly reduced the risk of target vessel-related revascularization (OR: 0.60 [95% CrI: 0.48 to 0.75]) but not OCT (OR: 0.86 [95% CrI: 0.60 to 1.19]), IVUS and OCT significantly reduced the risk of stent thrombosis (OR: 0.50 [95% CrI: 0.28 to 0.92]) and (OR: 0.48 [95% CrI: 0.22 to 0.98]), respectively, IVUS significantly reduced the risk of re-stenosis (OR: 0.65 [95% CrI: 0.46 to 0.88]) but not OCT (OR: 0.55 [95% CrI: 0.15 to 1.99]), neither IVUS (OR: 0.97 [95% CrI: 0.71 to 1.38]) nor OCT (OR: 0.75 [95% CrI: 0.49 to 1.22]) were associated with statistically significant reductions in all-cause mortality, neither IVUS (OR: 0.70 [95% CrI: 0.45 to 1.32]) nor OCT (OR: 0.81 [95% CrI: 0.47 to 1.59]) were associated with statistically significant reductions in target vessel failure, neither IVUS (OR: 0.88 [95% CrI: 0.43 to 2.44]) nor OCT (OR: 0.81 [95% CrI: 0.37 to 2.04]) were associated with statistically significant reductions in target lesion failure, and neither IVUS (OR: 0.82 [95% CrI: 0.60 to 1.06]) nor OCT (OR: 0.84 [95% CrI: 0.59 to 1.19]) were associated with statistically significant reductions in myocardial infarction. CONCLUSION: Intravascular imaging-guided, including IVUS and OCT, improved the postinterventional outcomes of PCI, notably suggesting their advantage over traditional angiography with no significant difference between IVUS and OCT.

Can the SYNTAX score predict mortality in patients with cardiac arrest?

OBJECTIVE: Sudden cardiac death or arrest describes an unexpected cardiac cause-related death or arrest that occurs rapidly out of the hospital or in the emergency room. This study aimed to reveal the relationship between coronary angiographic findings and cardiac death secondary to acute ST-elevation myocardial infarction. MATERIALS AND METHODS: Patients presenting with acute ST-elevation myocardial infarction complicated with cardiac arrest were included in the study. The severity of coronary artery disease, coronary chronic total occlusion, coronary collateral circulation, and blood flow in the infarct-related artery were recorded. Patients were divided into two groups, namely, deaths secondary to cardiac arrest and survivors of cardiac arrest. RESULTS: A total of 161 cardiac deaths and 42 survivors of cardiac arrest were included. The most frequent (46.3%) location of the culprit lesion was on the proximal left anterior descending artery. The left-dominant coronary circulation was 59.1%. There was a difference in the SYNTAX score (16.3±3.8 vs. 13.6±1.9; p=0.03) and the presence of chronic total occlusion (19.2 vs. 0%; p=0.02) between survivors and cardiac deaths. A high SYNTAX score (OR: 0.38, 95%CI: 0.27-0.53, p<0.01) was determined as an independent predictor of death secondary to cardiac arrest. CONCLUSION: The chronic total occlusion presence and SYNTAX score may predict death after cardiac arrest secondary to ST-elevation myocardial infarction.

Association of ACEI/ARB therapy with total and cardiovascular death in coronary artery disease patients with advanced chronic kidney disease: a large multi-center longitudinal study.

INTRODUCTION: Advanced chronic kidney disease (CKD) is common among patients with coronary artery disease (CAD), and angiotensin­converting enzyme inhibitors (ACEI) or angiotensin­receptor blockers (ARB) can improve cardiac and renal function, but whether ACEI/ARB therapy improves long-term prognosis remains unclear among these high-risk patients. Therefore, this research aimed to investigate the relationship between ACEI/ARB therapy and long-term prognosis among CAD patients with advanced CKD. METHODS: CAD patients with advanced CKD were included in five hospitals. Advanced CKD was defined as estimated glomerular filtration rate (eGFR)<30 ml/min per 1.73 m2. Cox regression models and competing risk Fine and Gray models were used to examine the relationship between ACEI/ARB therapy and all-cause and cardiovascular death, respectively. RESULTS: Of 2527 patients, 47.6% population of our cohort was discharged on ACEI/ARB. The overall all-cause and cardiovascular mortality were 38.6% and 24.7%, respectively. Multivariate Cox regression analyses indicated that ACEI/ARB therapy was found to be associated with lower rates of both all-cause mortality (hazard ratio (HR)=0.836, 95% confidence interval (CI): 0.738-0.948, p = 0.005) and cardiovascular mortality (HR = 0.817, 95%CI: 0.699-0.956, p = 0.011). In the propensity-matched cohort, the survival benefit was consistent, and significantly better survival was observed for all-cause mortality (HR = 0.856, 95%CI: 0.752-0.974, p = 0.019) and cardiovascular mortality (HR = 0.830, 95%CI: 0.707-0.974, p = 0.023) among patients treated with ACEI/ARB. CONCLUSION: ACEI/ARB therapy showed a better survival benefit among high-risk CAD patients with advanced CKD at long-term follow-up, which manifested that strategies to maintain ACEI/ARB treatment may improve clinical outcomes among these high-risk populations.

What is the current knowledge on the topic? Advanced CKD is highly prevalent and strongly associated with higher mortality risk and worse outcomes among CAD patients, and patients with advanced CKD have often been excluded from randomized controlled trials, creating an evidence gap for these high-risk CAD patients. ACEI/ARB are beneficial for greater survival among CAD patients, but the effect of ACEI/ARB therapy on long-term prognosis is unclear among CAD patients with advanced CKD.What does this study add to our knowledge? ACEI/ARB treatment showed a better survival benefit among high-risk CAD patients with advanced CKD at long-term follow-up.How might this change clinical pharmacology or translational science? CAD patients with advanced CKD are not only have worse outcomes but also limited in their choice of therapy strategies. Our study may prompt an important reference for the subsequent improvement of long-term prognosis among these high-risk populations.

Five-year outcomes of patients with diabetes mellitus treated with a sirolimus-eluting or a biolimus-eluting stents with biodegradable polymer. From the SORT OUT VII trial.

BACKGROUND: Diabetes mellitus is associated with higher risk of target lesion failure (TLF) after percutaneous coronary intervention. We studied the 5-year outcome in patients with diabetes mellitus treated with biodegradable polymer stents. METHODS: The SORT OUT VII was a randomised trial comparing the ultrathin sirolimus-eluting Orsiro stent (O-SES) and the biolimus-eluting Nobori stent (N-BES) in an all-comer setting. Patients (n = 2525) were randomised to receive O-SES (n = 1261, diabetes: n = 236) or N-BES (n = 1264, diabetes: n = 235). Endpoints were TLF (a composite of cardiac death, target-lesion myocardial infarction (MI), target lesion revascularization (TLR)), definite stent thrombosis and a patient related outcome (all-cause mortality, MI and revascularization) within 5 years. RESULTS: Patients with diabetes mellitus had higher TLF (20.6% vs 11.0%, (Rate ratio (RR) 1.85 95% confidence interval (CI): (1.42-2.40) and patient related outcome (42.0% vs 31.0%, RR 1.43 95% CI: (1.19-1.71)) compared to patients without diabetes. Among patients with diabetes mellitus, TLF after 5 years did not differ between O-SES and N-BES (21.2% vs 20.0%), RR 1.05 95% CI: (0.70-1.58), p = 0.81). Cardiac death, MI, TLR, and definite stent thrombosis did not differ between the groups. CONCLUSION: In patients with diabetes mellitus, 5-year outcomes were similar among patients treated with biodegradable polymer O-SES or N-BES. CLINICAL TRIAL REGISTRATION: URL: https://www.clinicaltrials.gov. Unique identifier: NCT01879358.

Effectiveness of low-dose rivaroxaban in preventing recurrent major adverse cardiovascular events in coronary artery disease: a systematic review and meta-analysis of randomized controlled trials.

INTRODUCTION: Despite advancements in coronary artery disease (CAD) management, major adverse cardiovascular events persist. Vitamin K antagonists and direct oral anticoagulants present bleeding risks. Low-dose rivaroxaban (2.5 mg) is approved by the European Society of Cardiology and the US Food and Drug Administration for CAD. The survival advantage and risk-benefit profile of combining low-dose rivaroxaban with aspirin for CAD patients remain uncertain. This meta-analysis aims to compare the efficacy of low-dose rivaroxaban plus aspirin versus aspirin monotherapy in CAD patients. METHODS: We systematically searched databases for randomized controlled trials exploring low-dose rivaroxaban with aspirin in CAD patients. Of the 6220 studies screened, five met the inclusion criteria. Primary outcomes included myocardial infarction, stroke, major bleeding events, and all-cause mortality. The analysis employed a fixed-effects model, calculating hazard ratios (HRs) and 95% confidence intervals (CIs). RESULTS: Five randomized controlled trials involving 41,351 participants were included. Rivaroxaban (2.5 mg) significantly reduced all-cause mortality (HR, 0.88; 95% CI, 0.81-0.95; P = 0.002), myocardial infarction (HR, 0.81; 95% CI, 0.70-0.94; P = 0.006), and stroke (HR, 0.61; 95% CI, 0.49-0.76; P < 0.00001) compared to aspirin alone. However, it increased major bleeding risk (HR, 1.66; 95% CI, 1.40-1.97; P < 0.01). Meta-regression revealed no dose-dependent impact on all-cause mortality. CONCLUSION: Low-dose rivaroxaban demonstrates survival benefits and reduces myocardial infarction and stroke risks in CAD patients, albeit with an increased risk of major bleeding. Consideration of patient bleeding risk is crucial when adding rivaroxaban to antiplatelet therapy. Further research is warranted to compare its effectiveness and safety with dual antiplatelet therapy or P2Y12 inhibitors.

Comparison of liberal versus restrictive transfusion strategies after hip surgery in patients with coronary artery disease: a post hoc analysis of the FOCUS trial.

BACKGROUND: There are no clear recommendations for optimal transfusion thresholds for patients with coronary artery disease who undergo noncardiac surgery. By comparing restrictive and liberal transfusion strategies for coronary artery disease combined with hip surgery, this study hopes to provide recommendations for transfusion strategies in this special population. METHODS: A total of 805 patients from the FOCUS trial (Transfusion Trigger Trial for Functional Outcomes in Cardiovascular Patients Undergoing Surgical Hip Fracture Repair) with coronary artery disease combined with hip surgery were divided into two groups based on transfusion thresholds: restricted transfusion (a hemoglobin level of 8 g/deciliter) and liberal transfusion (a hemoglobin threshold of 10 g/deciliter). The primary outcome of this study was a composite endpoint including in-hospital death, myocardial infarction, unstable angina, and acute heart failure. The secondary endpoints included other in-hospital adverse events and 30- and 60-day follow-up events. Analyses were performed by intention to treat. RESULTS: Except for the proportion of congestive heart failure patients, the baseline levels of the two groups were comparable. The median number of transfusion units in the liberal transfusion group was 2 units, and the median transfusion volume in the restricted transfusion group was 0 units. The primary outcome was not significantly different between the two groups (9.2% vs. 9.4%, p = 0.91). The incidence of in-hospital myocardial infarction events was lower in the liberal transfusion group than in the restricted transfusion group (3.2% vs. 6.2%) (OR = 0.51, P = 0.048). The remaining in-hospital endpoint events, except for myocardial infarction, were not significantly different between the two groups. The 30-day and 60-day endpoints of death and inability to walk independently were not significantly different between the two groups, with ORs (95% CI) of 1.00 (0.75-1.31) and 1.06 (0.80-1.41), respectively. We also found no interaction between transfusion strategies and factors such as age, sex, or multiple underlying comorbidities at the 60-day follow-up. CONCLUSIONS: There was no significant difference in the in-hospital, 30-day or 60-day outcome endpoints between the two groups. However, this study demonstrated that a liberal transfusion strategy tends to reduce the incidence of in-hospital myocardial infarction events in patients with coronary artery disease combined with hip surgery compared to a restrictive transfusion strategy. More high-quality studies should be designed to investigate the optimal transfusion threshold in patients with coronary artery disease treated without cardiac surgery.

The Combination Effect of the Red Blood Cell Distribution Width and Prognostic Nutrition Index on the Prognosis in Patients Undergoing PCI.

BACKGROUND: Inflammation and malnutrition are related to adverse clinical outcomes in patients with coronary artery disease (CAD). However, it is unclear whether there is a relationship between the PNI (prognostic nutritional index) and RDW (red blood cell distribution width) regarding the impact on the prognosis in patients with CAD undergoing percutaneous coronary intervention (PCI). METHODS: A total of 5605 consecutive CAD patients undergoing PCI were selected retrospectively. The patients were stratified into four groups according to the PNI [high PNI (H-PNI) and low PNI (L-PNI)] and RDW [high RDW (H-RDW) and low RDW (L-RDW)]. The cutoff values of RDW and PNI were calculated using receiver-operating characteristic curve analysis. The primary endpoint was 1-year all-cause mortality (ACM). The secondary endpoint was major adverse cardiac cerebrovascular events (MACCEs), the composite of cardiac death (CD), the recurrence of MI, target lesion revascularization (TLR), and stroke. A Cox proportional hazards model was used to evaluate the association between the PNI, RDW, and clinical endpoints. RESULTS: During 1-year follow-up, 235 (4.19%) patients died. In multivariate regression analysis, the L-PNI/H-RDW group was found to have the highest risk of 1-year ACM [hazard ratio (HR) = 8.85, 95% confidence interval (CI): 5.96-13.15, p = 0.020] with the H-PNI/L-RDW group as a reference, followed by the L-PNI/L-RDW (HR = 3.96, 95% CI: 2.60-6.00, p < 0.001) and H-RDW/H-PNI groups (HR = 3.00, 95% CI: 1.99-4.50, p < 0.001). Nomograms were developed to predict the probability of 1-year ACM and MACCEs. CONCLUSIONS: CAD patients with L-PNI and H-RDW experienced the worst prognosis. The combination of PNI and RDW was a strong predictor of 1-year ACM. The coexistence of PNI and RDW appears to have a synergistic effect, providing further information for the risk stratification of CAD patients.

Off versus on pump myocardial revascularization in patients with severe asymptomatic carotid stenosis.

BACKGROUND: Coronary artery disease is a global cause of morbidity and mortality, often managed by coronary artery bypass grafting (CABG). This study addresses a critical decision-making dilemma in CABG procedures for patients with severe asymptomatic carotid stenosis, comparing off-pump and on-pump techniques. METHODS: We conducted a retrospective single-center analysis, employing propensity scored matched-pair methodology to compare perioperative outcomes in patients with asymptomatic severe carotid stenosis undergoing off-pump or on-pump CABG. The primary endpoint was the occurrence of perioperative stroke. Secondary endpoints included postoperative delirium, intrahospital mortality, intensive care unit stay, length of hospitalization and long-term survival. RESULTS: The study involved 243 patients with asymptomatic severe carotid stenosis operated between July 2009 and October 2018, subsequently propensity score matched into two groups of 78 patients each (off-pump and on-pump). The incidence of perioperative stroke was significantly higher in the On-Pump group compared to the off-pump group (10.3% vs. 1.3%, P=0.03). However, secondary endpoints, such as intrahospital mortality and length of hospitalization, showed no significant differences between the two groups. Long-term survival rates were also comparable. CONCLUSIONS: Our findings indicate that off-pump CABG significantly reduces the risk of perioperative stroke in patients with severe asymptomatic carotid stenosis compared to on-pump CABG, without compromising long-term outcomes. These results support the preference for off-pump CABG in this high-risk patient population, highlighting the need for tailored surgical approaches based on individual patient risk profiles.

Value of Ischemia and Coronary Anatomy in Prognosis and Guiding Revascularization Among Patients With Stable Ischemic Heart Disease.

BACKGROUND: The value of physiological ischemia versus anatomic severity of disease for prognosis and management of patients with stable coronary artery disease (CAD) is widely debated. METHODS: A total of 1764 patients who had rest-stress cadmium-zinc-telluride single-photon emission computed tomography myocardial perfusion imaging and angiography (invasive or computed tomography) were prospectively enrolled and followed for cardiac death/nonfatal myocardial infarction. The CAD prognostic index (CADPI) was used to quantify the extent and severity of angiographic disease. Prognostic value was assessed using Cox models, adjusted for pretest risk, known CAD, stressor, left ventricular ejection fraction, %ischemia and infarct, CADPI, and early (90-day) revascularization. Incremental prognostic value was evaluated using net reclassification index. RESULTS: The mean age was 69.7±9.5 years, 24.4% were women, and 29.3% had known CAD. Significant ischemia (>10%) was present in 28.4%. Nonobstructive, single, and multivessel disease was present in 256 (14.5%), 772 (43.8%), and 736 (41.7%), respectively. Early revascularization occurred in 579 (32.8%). Cardiac death/myocardial infarction occurred in 148 (8.4%) over a 4.6-year median follow-up. Both %ischemia and CADPI provided independent and incremental prognostic value over pretest clinical risk (P<0.001). In a model containing both ischemia and anatomy, ischemia was prognostic (hazard ratio per 5% ↑, 1.35 [95% CI, 1.11-1.63]; P=0.002) but CADPI was not (hazard ratio per 10-unit ↑, 1.09 [95% CI, 0.99-1.20]; P=0.07). Early revascularization modified the risk associated with %ischemia (interaction P=0.003) but not with CADPI (interaction P=0.6). %Ischemia and single-photon emission computed tomography variables added incremental prognostic value over clinical risk and CADPI (net reclassification index, 20.3% [95% CI, 9%-32%]; P<0.05); however, CADPI was not incrementally prognostic beyond pretest risk, %ischemia, and single-photon emission computed tomography variables (net reclassification index, 3.1% [95% CI, -5% to 15%]; P=0.21). CONCLUSIONS: Ischemic burden provides independent and incremental prognostic value beyond CAD anatomy and identifies patients who benefit from early revascularization. The anatomic extent of disease has independent prognostic value over clinical risk factors but offers limited incremental benefit for prognosis and guiding revascularization beyond physiological severity (ischemia).

Prognosis impact of multiple novel lymphocyte-based inflammatory indices in patients with initially diagnosed coronary artery disease.

BACKGROUND: This study aimed to evaluate six novel lymphocyte-based inflammatory markers (neutrophil-lymphocyte ratio, monocyte-lymphocyte ratio, platelet-lymphocyte ratio [PLR], systemic immune inflammation index [SII], systemic inflammatory response index, and systemic immune inflammation response index [SIIRI]) in patients with newly diagnosed coronary artery disease [CAD]. METHODS: A total of 959 patients newly diagnosed with CAD and underwent diagnostic coronary angiography were enrolled in this study and followed for major adverse cardiovascular events (MACEs), including cardiovascular death, nonfatal myocardial infarction, and nonfatal stroke. The best cutoff value was used to compare the six indicators. Cox risk regression analysis evaluated the relationship between novel lymphocyte-based inflammatory markers and MACEs in newly diagnosed CAD patients. RESULTS: During a mean follow-up period of 33.3 ± 9.9 months, 229 (23.9%) MACEs were identified. Multivariate Cox regression analysis showed that only SIIRI (hazard ratio [HR]: 5.853; 95% confidence interval [CI]: 4.092-8.371; p < .001) and PLR (HR: 1.725; 95% CI: 1.214-2.452; p = .002) were independent predictors of MACEs. Nevertheless, following the adjustment for covariates, only the SIIRI was found to be a significant predictor MACEs and its corresponding specific endpoint occurrences. The predictive ability of the model was improved when six different inflammatory markers were added to the basic model established by traditional risk factors, namely, the C-index increased, and the SIIRI increased most significantly (AUC: 0.778; 95% CI: 0.743-0.812; p < .001). However, among the six novel inflammatory markers, only SIIRI had improved net reclassification improvement (NRI) and integrated discrimination improvement (IDI) (NRI: 0.187; 95% CI: 0.115-0.259, p < .001. IDI: 0.135; 95% CI: 0.111-0.159, p < .001), which was superior to the basic model established by traditional risk factors. CONCLUSIONS: SIIRI is independent predictor of MACEs in newly diagnosed CAD patients. SIIRI was superior to other measures in predicting MACEs. The combination of SIIRI and traditional risk factors can more accurately predict MACEs.