SASSICAIA Trial Showed No Difference Between Intensified Prasugrel-Based and Standard Clopidogrel-Based Loading Strategies in Terms of Safety and Efficacy in Patients Undergoing Elective Percutaneous Coronary Intervention

A recent study by Dr. Julinda Mehilli, M.D., published in Circulation journal, has shown that in patients undergoing elective percutaneous coronary intervention (PCI), pretreatment strategy with the intensified prasugrel loading does not differ from standard clopidogrel loading dose in terms of Safety and Efficacy. According to the trial, both strategies can be safely applied among patients undergoing elective PCI.
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Post Hoc Analysis of Randomized SCOT-HEART Trial: Coronary Computed Tomography Is More Strongly Associated With 5-Year Coronary Events Compared With Exercise Electrocardiography

The post hoc analysis of the SCOT-HEART trial by Dr. Adamson MBChB, Ph.D. published in JAMA Cardiology showed that abnormal results of exercise electrocardiography (ECG) were strongly associated with coronary revascularization and increased risk of mortality from coronary heart disease. However, coronary computed tomography (CT) angiography was a more accurate predictor of 5-year coronary events compared with exercise ECG alone. Continue reading

In a Recent Large Cohort Renin–Angiotensin–Aldosterone System Inhibitors Were Not Associated with Increased Risk of COVID-19 and Severe Illness

Medications acting on the renin-angiotensin-aldosterone system (RAAS), such as ACE inhibitors and angiotensin receptor blockers, did not increase the likelihood of a positive test for Covid-19 or the severity of the Covid-19. A cohort study of more than 12,500 patients conducted in a large health network in New York City, led by Dr. Reynolds, revealed. The findings of the study were recently published in the New England Journal of Medicine. Continue reading

Study Shows Patient Self Reports Overestimated And Pharmacy Fills Underestimated Medication Persistence Agreement and Accuracy of Medication Persistence Identified by Patient Self-report vs Pharmacy Fill A Secondary Analysis of the Cluster Randomized ARTEMIS Trial

In an original investigation done by Dr. Alexander C. Fanaroff et al and recently published in JAMA Cardiology, it was found that there was discordance in medication persistence as measured by patient-reported and the pharmacy fill data. The patient self-reports overestimated and pharmacy fill data underestimated medication persistence. Those who had non-persistence by both measures had the highest rate of major adverse cardiovascular events (MACE). The authors also noted the need for giving preference to interventions that will promote medication-taking behavior. Continue reading

Long-Term Follow-Up of the REDUCE-MVI Trial Showed the Superiority of Ticagrelor Over Prasugrel in Maintenance Therapy of Patients With ST-Segment-Elevation Myocardial Infarction

A recent study by Dr. van der Hoeven, published in the Journal of American Heart Association, has shown the superiority of ticagrelor over prasugrel in patients presenting with ST-segment-elevation myocardial infarction (STEMI). According to the author, ticagrelor has a higher efficacy in platelet inhibition as well as in improving endothelial function when compared with prasugrel. Continue reading

Study Shows Myocardial Perfusion Mapping Using Artificial Intelligence Quantification of Cardiovascular Magnetic Resonance Imaging Provides Prognostic Information in Patients With Suspected Coronary Artery Disease Above Traditional Cardiovascular Risk Factors

A recent study by Dr. Knott, published in Circulation, have shown the prognostic value of measuring myocardial blood flow (MBF) using artificial intelligence quantification of cardiovascular magnetic resonance (CMR) perfusion mapping in cardiovascular outcomes. According to this study, both MBF and myocardial perfusion reserve (MPR) were associated with death and major adverse cardiovascular events (MACE) independently of other clinical risk markers. Using this technique, quantitative analysis of myocardial perfusion for clinical use is now available. Continue reading

1K Plaque Associated With Lower Future ACS Risk: Case Control Cohort Study (Analysis from ICONIC Study) Association of High-Density Calcified 1K Plaque With Risk of Acute Coronary Syndrome

In an original investigation by Dr. Alexander R. van Rosendael et al recently published in JAMA Cardiology, it was found that the higher-density calcified plaque, referred to as 1K plaque was associated with a reduced risk for future Acute Coronary Syndromes (ACS). The authors also support the hypothesis of plaque stabilization with coronary calcium with the results of this analysis of Incident Coronary Syndromes Identified by Computed Tomography (ICONIC) study and are considerate of different risk stratifications that can be detected in atherosclerotic plaque beyond its burden. Continue reading

Population-Based Cohort Study Shows Blood Pressure Trajectories Over The Life Course Progress More Rapidly in Women Compared to Men

A new study by Dr. Hongwei, published in JAMA Cardiology, demonstrated that blood pressure (BP) trajectories over the life course progress more rapidly in women compared to men, a process that begins as early as the third decade of life. This concept is inconsistent with the previously accepted notion that important vascular disease processes in women occur by 10 to 20 years delay compared to men. These sex-based differences in physiology may establish the cornerstone for future cardiovascular disorders that often present differently in women compared with men.

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Randomized Trial Shows Prasugrel Associated with Better Endothelial Function and Stronger Platelet Inhibition as Compared to Clopidogrel or Ticagrelor in Patients with ACS Who Undergo Stenting

In a recent randomized, three-arm, parallel, blinded study by Dr. Schnorbus, published in European Heart Journal, prasugrel was associated with improved endothelial function, more potent platelet inhibition, and decreased plasma interleukin (IL)-6 levels in patients undergoing stent placement for acute coronary syndrome (ACS) compared to ticagrelor and clopidogrel. These effects were observed in patients who received prasugrel 2 hours before stenting.

Coronary artery stenting has been associated with impaired coronary and peripheral endothelial function as well as an inflammatory response leading to the release of mediators and subsequent platelet aggregation. These phenomena are associated with in-stent restenosis as well as adverse prognostic outcomes after percutaneous coronary intervention (PCI). Platelet inhibitors, such as P2Y12 receptor inhibitors, are administered prior and after coronary interventions to address these adverse effects. However, previous studies have suggested that differences exist among P2Y12 inhibitors in terms of their efficacy.

In a prospective, single-center study, a total of 90 patients with unstable angina or non-ST elevation myocardial infarction (NSTEMI) undergoing coronary stenting were randomized to receive a single dose of clopidogrel (600mg), prasugrel (60mg), or ticagrelor (180mg) followed by chronic therapy with the same drug. Patients with elevated c reactive protein (CRP), infective or inflammatory disorders, personal history of prior coronary interventions, impaired hepatic/renal function, those with heart failure, and those with ST elevation myocardial infarction (STEMI) were excluded from the study. The primary endpoint of the study was the change in flow-mediated dilation (FMD) of the conduit artery over a period of 1 day, 1 week, and 1 month after PCI. Secondary endpoints were the effect of study medications on macrovascular and microvascular function, platelet aggregation, and inflammatory stress.

The study showed that antiplatelet therapy immediately before stenting was associated with improved FMD without a significant difference among study medications. On the first follow-up after PCI and later follow-up visits, prasugrel was associated with a stronger platelet reactivity inhibition and improved endothelial function. These effects were limited to those who received prasugrel before catheterization. Prasugrel platelet inhibitory effect was more obvious in NSETMI patients than in those with unstable angina. Prasugrel therapy also led to a more pronounced decrease in IL-6 levels. According to the author, “when administered pre-PCI, prasugrel, but not the other agents, limits stent-induced endothelial dysfunction and inflammation in ACS.” This study is limited by its small size and future studies are needed to further confirm these conclusions.

 

SYNTAX III REVOLUTION Trial: Non-invasive CT Scanning as a Potential Alternative to Invasive Coronary Angiography for Treatment Decision-Making in Patients with Complex Coronary Artery Disease FFRCT or multi-slice CT scanning changed heart team’s treatment decision-making and procedural planning in 1/5th of the patients

A cross-sectional observational study enrolling 223 patients with 3-vessel coronary artery disease, has shown that compared to conventional invasive coronary angiography, a noninvasive physiology assessment using fractional flow reserve CT scanning (FFRCT or multi-slice CT scanning) changed heart team’s treatment decision-making and procedural planning in 1/5th of the patients.

The SYNTAX III REVOLUTION Trial was a randomized, multi-center study which randomized two heart teams to make a treatment decision between percutaneous coronary interventions (PCI) and coronary artery bypass grafting (CABG) using either coronary computed tomography angiography (CTA) or conventional invasive angiography while blinded to the other imaging modality. The study included patients with complex coronary artery disease, defined as, left main (isolated, or associated with 1, 2 or 3 vessel disease) or de novo 3-vessel coronary artery disease (DS ≥50%), who were able to receive cardiac CT with a multi-slice CT scanner. Coronary CTA was performed with the GE Revolution CT scanner that has a nominal spatial resolution of 230 microns along the X–Y planes, a rotational speed of 0.28 s, and a Z-plane coverage of 16 cm enabling to image the heart in one heartbeat. Patients with concomitant atrial fibrillation, cardiac valve disease and prior history of PCI or CABG were excluded from the study. The primary outcome was the inter-rater agreement (assessed by Cohen’s Kappa Kappa; a value of 0.82) on revascularization strategy of two heart teams by employing the use of either an “Angio-first” algorithm or a “CT First” algorithm 1 to 2 weeks after patient enrollment. The addition of FFRCT changed the treatment decision in 7% of the patients and modified selection of vessels for revascularization in 12%. With conventional angiography as a reference, FFRCT assessment resulted in reclassification of 14% of patients from intermediate and high to low SYNTAX score tertile.

The American and European guidelines recommend a heart team based approach for the decision-making process regarding the revascularization strategy and recommend the evaluation of the anatomical complexity using the SYNTAX score. Patients with SYNTAX scores >34 have been found to do much better with bypass surgery than those with lower SYNTAX scores. The SYNTAX scores can be divided into three tertiles. Higher scores signify complex conditions and indicate greatest risks to patients undergoing PCI. Calculation of the SYNTAX score takes into account complex lesions including bifurcations, chronic total occlusions, thrombus, calcification, and small diffuse disease with a total of 11 measures of lesion complexity. The score ranges from 0 to greater than 60 in very complex coronary anatomy.

Previously validated SYNTAX II score utilizes SYNTAX I score and then combines it with clinical prognostic variables such as age, creatinine clearance, gender, left main vessel involvement, left ventricular ejection fraction, chronic obstructive pulmonary disease (COPD) and peripheral vascular disease (PVD) in order to guide selection between PCI and CABG for patients with multivessel coronary disease. The results of the SYNTAX III Trial suggest the potential feasibility of a treatment decision-making and planning that stems from a non-invasive imaging modality and clinical information.

Enhanced Vasospasm And Reduced Vasodilator Function Linked To Worse Outcomes In Patients With Non-Obstructive Coronary Arteries In patients with vasospastic angina, high IMR (≥ 18) correlated with increased incidence of major adverse cardiovascular events

A single center study that included 187 patients who presented with angina-like chest pain and nonobstructive coronary arteries on diagnostic angiography, has shown that co-existence of high microvascular resistance index (IMR) and vasospasm is associated with an increased incidence of major adverse cardiovascular events (MACE – defined as cardiac death, nonfatal myocardial infarction, and hospitalizations). Rho-kinase activation thought to underlie mechanisms leading to high IMR in this patient population.
The 187 patients included in the study had a median follow-up of 893 days. Continue reading

Treatment with Statins, RAAS Inhibitors and Platelet Inhibitors After CABG is Essential, While the Use of Beta-blockers is Questionable: Swedish Study Secondary prevention medications after coronary artery bypass grafting and long-term survival: a population-based longitudinal study from the SWEDEHEART registry

In a recent study published in the European Heart Journal, Erik Björklund et al. found that the secondary prevention medications, such as statins and renin-angiotensin-aldosterone system (RAAS) inhibitors, and platelet inhibitors used after coronary artery bypass grafting (CABG) are essential while the use of B-blockers had no association with survival and is questionable.

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ORION-1: 1-Year Follow-Up Data Affirms 2-dose Regimen Using 300 mg of Inclisiran For Persistent LDL-C Lowering 360-day follow-up results published in September edition of JAMA Cardiology

A randomized, double blind, placebo-controlled, phase II clinical trial studying the effect of a novel protein proprotein convertase subtilisin/kexin type 9 (PCSK9) synthesis inhibitor (inclisiran) on serum low density lipoprotein cholesterol (LDL-C) levels has shown that twice a year subcutaneous injections of inclisiran leads to a sustained dose-dependent reduction in serum LDL-C levels over a period of 1 year.

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The COMPLETE Timing Substudy: A Randomized Trial of Complete Staged Revascularization Vs. Infarct Artery PCI Alone in Patients With Acute Myocardial Infarction and Multivessel Disease – Importance of Revascularization Timing

The results of a substudy of the COMPLETE Trial were presented at TCT 2019 by Dr. David Wood, an interventional cardiologist, and Professor of Medicine at the University of British Columbia, Canada. The analyses revealed that compared with culprit-lesion only PCI, the timing of complete revascularization, whether performed early during the index hospitalization or after discharge have similar benefits on major cardiovascular events.

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TWILIGHT Trial: Single Anti-Platelet Therapy (SAPT) Using Ticagrelor Reduces Bleeding Risk And Preserves Ischemia Prevention Post-PCI Following 3 months of dual anti-platelet therapy (DAPT) post-PCI, continuation of anti-ischemic pharmacotherapy with ticagrelor alone safer than extended DAPT

A randomized, double-blinded, placebo-controlled trial which enrolled 7119 high risk  patients with coronary artery disease who had undergone recent percutaneous coronary intervention (PCI) has shown that, after 3 months of dual anti-platelet therapy (DAPT) using a P2Y12 receptor blocker (ticagrelor) and aspirin, continuing secondary prevention with a single anti-platelet therapy (SAPT) with ticagrelor alone reduces bleeding as compared to extended DAPT.

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EWTOPIA 75 Trial: Lowering LDL-Cholesterol with Ezetimibe Prevents Cardiovascular Events in the Elderly

Individuals older than 75 years treated with ezetimibe had a significantly lower risk of atherosclerotic cardiovascular events over 4 years compared with standard care, according to the results of the EWTOPIA 75 trial recently published in Circulation.

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REVELATION Trial: Paclitaxel-Coated Balloon Angioplasty is Non-Inferior To The Routinely Conducted Drug-Eluting Stenting in STEMI Patients A 9 months follow-up Single-Centered Randomized Clinical Trial

According to a recent study based on the REVELATION Trial, conducted by Nicola S. Vos et al. and published in JACC, Paclitaxel-coated balloon angioplasty was documented to be non-inferior to the routine drug-eluting stenting (DES) in ST-segment elevation myocardial infarction (STEMI) patients.

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HOPE 4: A Comprehensive Community-based Program Surpassing the Barriers in Improving BP Control and Associated Cardiovascular Disease Risk in 2 Middle Income Countries A successful 12-months follow-up open-labeled, cluster-randomized controlled trial

Significant improvement in blood pressure control and related cardiovascular disease (CVD) risk is seen as a result of a potentially effective and pragmatic comprehensive model of care conducted as HOPE 4 trial (Heart Outcomes and Prevention Evaluation-4) presented by Dr. JD Schwalm at the European Society of Cardiology (ESC) Congress 2019 and simultaneously published in The LANCET.

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No significant association between myocardial viability & long-term survival benefit of CABG in patients with ischemic cardiomyopathy Results of a 10-year follow-up STICH trial & subsequent myocardial viability sub-study

According to a new study published in The New England Journal of Medicine (NEJM) based on a 10-year follow-up STICH trial, no association was found between myocardial viability as a long-term survival benefit of CABG in patients with ischemic cardiomyopathy.

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SYNTAXES Study: No Significant Difference In All-Cause Death At 10 Years Between PCI and CABG Results of a 10-year Follow-up Study presented at the European Society of Cardiology (ESC) Congress 2019

A follow-up of a multicenter, randomized controlled trial, the results of which were debuted at the European Society of Cardiology (ESC) Congress 2019, has shown that at 10 years, no statistically significant difference existed in all-cause mortality between percutaneous coronary intevention (PCI) using first-generation paclitaxel-eluting stents and coronary artery bypass grafting (CABG). However, CABG was shown to provide significant survival benefit in patients with three-vessel disease, but not in patients with left main coronary artery disease.

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