Background: The optimal method of coronary revascularization among patients with diabetes mellitus (DM) and multivessel coronary artery disease (CAD) complicated by chronic kidney disease (CKD) remains unknown.
A 71-year-old man underwent successful percutaneous coronary intervention to treat a chronic total occlusion (CTO) of the left circumflex artery (LCx) with implantation of a 3.0 × 18-mm and 2.5 × 28-mm Absorb bioresorbable scaffold (BRS) (Abbott Vascular, Santa Clara, California) (Figure 1) (1). A further BRS was implanted in the first major obtuse marginal branch (OM1).
The planning of revascularization strategy for multivessel coronary artery disease (CAD) in nondiabetic patients is optimally made through considering the goals of improving survival and/or relieving symptoms. Existing clinical practice guidelines and appropriate use criteria (1–3) state that in nondiabetic patients with multivessel CAD and stable ischemic heart disease (SIHD), either coronary artery bypass grafting (CABG) or percutaneous coronary intervention (PCI) with drug-eluting stents may be used for those with low SYNTAX (Synergy Between PCI With Taxus and Cardiac Surgery) scores, but CABG is preferred for those with intermediate or high SYNTAX scores. In the overall SYNTAX population (4–6), the rates of death and stroke were similar, but the risk of myocardial infarction (MI) and repeat revascularization were higher in PCI-treated patients. At 5-year follow-up, the rates of death/stroke/MI are 8.0% lower, and the rate of repeat revascularization is 12.8% lower in CABG-treated patients. In the low SYNTAX score tertile, these trends are not significantly different, but they are in the intermediate and high SYNTAX score subsets. When considering only survival in the 3 tertiles, there was a 0.9%, 6.7%, and 9.0% difference over 5 years, an average of 0.2% to 1.8% per year. Yet, PCI is more often performed in multivessel CAD patients, despite the guidelines and clinical evidence. Can this apparent divergence from the evidence base be supported? Drs. Weintraub and Tcheng and colleagues were asked to defend or critique the current guidelines.
Abstract: Ischemic heart disease is a complex disease process caused by the development of coronary atherosclerosis, with downstream effects on the left ventricular myocardium. It is characterized by a long preclinical phase, abrupt development of myocardial infarction, and more chronic disease states such as stable angina and ischemic cardiomyopathy. Recent advances in computed tomography (CT) and cardiac magnetic resonance (CMR) now allow detailed imaging of each of these different phases of the disease, potentially allowing ischemic heart disease to be tracked during a patient’s lifetime. In particular, CT has emerged as the noninvasive modality of choice for imaging the coronary arteries, whereas CMR offers detailed assessments of myocardial perfusion, viability, and function. The clinical utility of these techniques is increasingly being supported by robust randomized controlled trial data, although the widespread adoption of cardiac CT and CMR will require further evidence of clinical efficacy and cost effectiveness.
Background: Angina is common in hypertrophic cardiomyopathy (HCM) and is associated with abnormal myocardial perfusion. Wave intensity analysis improves the understanding of the mechanics of myocardial ischemia.
Background: In severely symptomatic patients with obstructive hypertrophic cardiomyopathy (HCM) and mild septal hypertrophy, mitral valve (MV) abnormalities may play an important role in MV displacement into the left ventricular (LV) outflow tract. Therefore, isolated myectomy may not relieve outflow obstruction and symptoms, and MV replacement is often the surgical alternative.
Abstract: Atherosclerotic cardiovascular disease (ASCVD) events, including coronary heart disease and stroke, are the most frequent cause of death and major disability in the world. Current American College of Cardiology/American Heart Association primary prevention guidelines are mainly on the basis of randomized controlled trials of statin-based low-density lipoprotein cholesterol (LDL-C)–lowering therapy for primary prevention of ASCVD events. Despite the clear demonstration of statin-based LDL-C lowering, substantial 10-year and lifetime risks of incident ASCVD continue. Although the 10-year risk is low in young and middle-aged adults who would not be treated according to current guidelines, they ultimately account for most incident ASCVD. If statin-based LDL-C lowering were initiated in them at an age before complex coronary plaques are common in the population, a substantial reduction in lifetime risk of incident coronary heart disease might be achieved. We examine this hypothesis and introduce the design of a currently recruiting trial to address it. (Eliminate Coronary Artery Disease [ECAD]; NCT02245087)
Background: Treatment of multivessel coronary artery disease with traditional single-arterial coronary artery bypass graft (SA-CABG) has been associated with superior intermediate-term survival and reintervention compared with percutaneous coronary intervention (PCI) using either bare-metal stents (BMS) or drug-eluting stents (DES).
Background: Data for left ventricular assist devices (LVADs) in patients with noninotrope-dependent heart failure (HF) are limited.
Background: Insufficient procedural efficacy has been proposed to explain nonresponse to renal denervation (RDN).
Background: Previous studies report that CHADS2 and CHA2DS2-VASc risk scores have similar discriminating ability (C statistic ∼0.6). Recently a clinically based risk score, the ATRIA (Anticoagulation and Risk Factors in Atrial Fibrillation) study risk score, was developed and validated.
Background: Bioresorbable scaffolds provide transient lumen support followed by complete resorption.
Abstract: Recognition of ischemic heart disease (IHD) is often delayed or deferred in women. Thus, many at risk for adverse outcomes are not provided specific diagnostic, preventive, and/or treatment strategies. This lack of recognition is related to sex-specific IHD pathophysiology that differs from traditional models using data from men with flow-limiting coronary artery disease (CAD) obstructions. Symptomatic women are less likely to have obstructive CAD than men with similar symptoms, and tend to have coronary microvascular dysfunction, plaque erosion, and thrombus formation. Emerging data document that more extensive, nonobstructive CAD involvement, hypertension, and diabetes are associated with major adverse events similar to those with obstructive CAD. A central emerging paradigm is the concept of nonobstructive CAD as a cause of IHD and related adverse outcomes among women. This position paper summarizes currently available knowledge and gaps in that knowledge, and recommends management options that could be useful until additional evidence emerges.
Abstract: Mitral annulus calcification (MAC) is a chronic, degenerative process in the fibrous base of the mitral valve. Although MAC was initially thought to be an age-related degenerative process, there is accumulating evidence that other mechanisms, such as atherosclerosis and abnormal calcium-phosphorus metabolism, also contribute to the development of MAC. Despite its frequency, the clinical relevance of MAC is grossly underappreciated. Indeed, MAC is associated with an increased incidence of cardiovascular disease, mitral valve disease, arrhythmias, and mortality. MAC also influences the outcomes of cardiac surgery and interventions, and its clinical relevance may well increase substantially in the forthcoming era of transcatheter mitral valve replacement. In this paper, we review the available published data to provide a consistent, clinically relevant description of MAC on the basis of contemporary imaging. We describe the pathophysiological mechanisms contributing to the formation of MAC and the clinical implications of this disease entity.
Background: Differences between sexes in cardiac risk factors, perceptions of cardiac risk, and health care provider discussions about risk among young patients with acute myocardial infarction (AMI) are not well studied.
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