Trans-stenotic pressure gradient as derived from CT improves patient management: ADVANCE registry

Background The change in fractional flow reserve derived from CT (FFRCT) value across a coronary stenosis (ΔFFRCT) improves the physiological characterization of coronary artery disease (CAD). The role of ΔFFRCT in guiding risk-stratification and downstream testing in patients with stable CAD is unknown. Purpose To investigate the incremental value of ΔFFRCT at predicting early revascularization and improving efficacy of resource utilization. Methods Patients with CAD on CT coronary angiography (CTCA) were enrolled in an international multicenter registry. Patients with non-evaluable FFRCT analysis were excluded. The CTCA was assessed for: stenosis severity as per CAD-Reporting and Data System (CAD-RADS), lesion length and lesion-specific FFRCT measured 2 cm distal to stenosis. Risk factors and actual treatment (revascularization vs medical therapy) at 90-day follow-up were recorded. Multivariable logistic regression analysis for early revascularization was conducted. The incremental discrimination for revascularization prediction was compared among 3 models (model 1: risk factors + lesion length and location + CAD-RADS; model 2: model 1 + lesion-specific FFRCT; model 3: model 2 + ΔFFRCT). Simulating ICA referral for patients with CAD-RADS ≥3 and lesion-specific FFRCT ≤0.8, the potential impact of ΔFFRCT at reducing ICA referral and improving the ratio of subsequent revascularization was assessed. Results Of 4730 patients (66±10 years; 34% female), 2092 (42.7%) underwent ICA and 1168 (24.7%) underwent early revascularization. With increasing ΔFFRCT, a higher incidence of revascularization (Figure 1A) and an increase in the revascularization to ICA ratio was observed (Figure 1B). ΔFFRCT >0.13 was the optimal cut-off for predicting revascularization as determined by the Youden index. ΔFFRCT remained an independent predictor for early revascularization (odds ratio per 0.05 increase with 95% CI, 1.31 [1.26–1.35]; p<0.0001) after adjusting for risk factors, CAD-RADS, lesion length and location, and FFRCT. Among the 3 models, model 3, which included ΔFFRCT showed the highest AUC and improved discrimination power compared to model 2 (0.87 [0.86–0.88] vs 0.85 [0.84–0.86]; p<0.0001] (Figure 2), with the greatest incremental value for ΔFFRCT observed in patients with lesion-specific FFRCT between 0.71–0.80. In patients with CAD-RADS ≥3 and lesion-specific FFRCT ≤0.8, a diagnostic strategy incorporating ΔFFRCT >0.13 would potentially reduce ICA referral by 32.2% (1638 to 1110) and improve the revascularization to ICA ratio from 65.2% [1068/1638] to 73.1% [811/1110]. Conclusions The characterization of CAD with ΔFFRCT improves the identification of patients requiring early revascularization as compared to a standard diagnostic strategy of CTCA with FFRCT, particularly for those with lesion-specific FFRCT of 0.71–0.80. ΔFFRCT has the potential to aid decision making for ICA referral and improve the efficiency of resource utilization. FUNDunding Acknowledgement Type of funding sources: Private company. Main funding source(s): HeartFlow, Inc., Redwood City, CA, USA ΔFFRCT and actual treatment ROC curve for early revascularization

Lead aVR predicts early revascularization but not long-term events in patients referred for stress electrocardiography

Background Exercise stress electrocardiography (ExECG) is recommended as a first-line tool to assess ischemia, but standard ST-analysis has limited diagnostic accuracy. ST elevation in lead aVR has been associated with left main and LAD disease in the population undergoing coronary angiography but has not been studied in the general population undergoing stress testing for the initial evaluation of CAD without coronary angiography. We sought to determine the predictive value of lead aVR elevation for ischemia, early revascularization, and subsequent cardiac events in consecutive patients undergoing ExECG. Methods and results The study cohort included 641 subjects referred for ExECG who were dichotomized by presence or absence of aVR elevation ≥1mm and compared for prevalence and predictors of ischemia and a composite of cardiac death, nonfatal myocardial infarction, and late revascularization. The cohort had a median age of 57 and 57% were male. The prevalence of aVR elevation was 11.5%. The prevalence of significant ischemia on patients who received imaging was significantly higher with aVR elevation (14.3% vs 2.3%, p<0.001). Early revascularization occurred in 10.9% with vs 0.2% without aVR elevation, p<0.001. No subjects without aVR elevation or ST-depression underwent early revascularization. However, cardiac event rates were similar over a median 4.0 years of follow-up with and without aVR elevation (2.8% vs. 2.6%, p = 0.80). aVR elevation did not predict long-term cardiac events by Kaplan-Meier survival analysis (p = 0.94) or Cox proportional hazards modeling (p = 0.35). Conclusions aVR elevation during ExECG predicts ischemia on imaging and early revascularization but not long-term outcomes and could serve as a useful adjunct to standard ST-analysis and potentially reduce the need for concurrent imaging.

Cardiogenic Shock Due to ST Elevation Myocardial Infarction: How Far Are We?

Cardiogenic shock (CS) due to acute ST-elevation myocardial infarction is a complex state of low cardiac output and hemodynamic instability that transmutes to hypoperfusion of various body tissues leading to multi-organ dysfunction and death. Mortality rates due to CS remain high despite many recent advances in treatment. In the management of CS, early revascularization is the mainstay of the treatment. The patient can be stabilized using fl uids, vasopressors or inotropes, mechanical circulatory support, and general intensive care techniques. Due to only few randomized trials on CS patients, there is lack of concrete evidence supporting various treatment modalities, except for revascularization. Thus, CS and its management is a topic with more controversies than conclusions regarding optimal treatment and management.

Male with Long Standing Heart Failure and Left Bundle Branch Block with Acute Chest Pain: Is It Needed for Urgent Revascularization?

Background : Patients with acute heart failure and left bundle branch block (LBBB) presenting acute chest pain have many clinical challenges to perform the diagnostic and therapeutic process. Recent recommendations revealed that the patients with LBBB (new or presumably new) should be performed early revascularization. However, several clinical controversies occurred due to scientific gaps between current evidence and recommen- dations. Therefore, the review of other approaches to assess this setting might be required. Objective : This case report aims to describe factors related to early revascularization strategy in patients with long standing heart failure and left bundle branch block. Case : A 46-year-old man with the previous history of dyspnea (long-standing heart failure) was admitted to our hospital with recurrent chest pain and acute heart failure. Electrocardiogram (ECG) showed LBBB suggesting acute myocardial infarction (excessive discordance in the precordial lead). He had normal serial cardiac enzymes with ongoing ischemia symptoms. He had been decided not to perform urgent reperfusion therapy. After five days of hospitalization, he discharged home with medicines. Our case report provided an example of applying the existing algorithm to assess acute chest pain in congestive heart failure, regardless of ST-segment deviation in LBBB. Conclusion : Clinical judgement and the use of objective findings offer the best way to determine the need for early reperfusion in our case.

Myocardial perfusion scintigraphy for risk stratification of patients with coronary artery disease: the AMICO registry

Aims We assessed the prognostic value of myocardial perfusion scintigraphy (MPS) with cadmium–zinc–telluride in addition to clinical and coronary anatomy analysis. Methods and results We prospectively enrolled 1464 patients (26% females, 69.5 ± 10.4 years) referred for stress-rest MPS. All the patients underwent invasive coronary angiography (1171, 80%) or coronary computed tomography angiography (293, 20%). We defined a composite endpoint of cardiovascular death and non-fatal MI. After an 8-year follow-up, summed stress score (SSS) had the highest accuracy in predicting primary endpoint with a ROC-derived cut-off of SSS &gt;8 (&gt;10% myocardium). SSS &gt;8 portended the lowest survival probability at Kaplan–Meier analysis (P &lt; 0.0001 for the composite endpoint and individual components). The Cox-regression analysis indicated SSS as an independent predictor of the composite endpoint, along with fasting blood glucose and total cholesterol and contrary to coronary anatomy parameters. Patients with SSS &gt;8 treated with optimal medical therapy (OMT) had the largest area of necrosis, the lower ischaemic burden, the most compromised LV systo-diastolic function and the highest LV mass, but received a less aggressive treatment in comparison to early revascularized patients. Survival analysis revealed patients with SSS ≤8 had the greater freedom from events, irrespective of the treatment strategy, while the group with SSS &gt;8 and OMT had the worst outcome, followed by patients with SSS &gt;8 and early revascularization (log-rank test: all P &lt; 0.0001). Conclusion MPS-SSS constitutes a strong independent predictor of future adverse events after adjustment for multiple clinical parameters and coronary angiography. In particular, MPS could help risk stratification of patients who did not undergo early revascularization.

Abstract 15943: Health Status and Quality of Life With Early Invasive and Non-invasive Treatment Strategies for Patients With Claudication

Introduction: Improving health status; symptoms, function, and quality of life (QoL) are key treatment goals in patients with peripheral arterial disease (PAD) and claudication. Hypothesis: Compared with medical management only, early revascularization in patients with claudication is associated with greater improvements in disease-specific health status. Methods: Patients with new or worsening claudication, who underwent revascularization within 3 months of enrolment or were treated non-invasively (statin, aspirin, cilostazol, supervised exercise therapy, risk factor management) were identified from 16 vascular medicine clinics in the US, Netherlands and Australia participating in the PORTRAITregistry. Patients were propensity-matched on the likelihood of receiving invasive therapy. The Peripheral Artery Questionnaire (PAQ) was used to assess patients’ disease-specific health status at enrollment, and at 3, 6 and 12 months of follow-up using hierarchical Generalized Linear Models for repeated measures. Results: Among 1142 patients (mean age of 67.7 years, 63.0% male), 229 (20.1%) underwent early revascularization while 913 (79.9%) were managed non-invasively. At baseline, patients who underwent invasive vs. non-invasive management had lower PAQ summary (mean ± SD; 44.41 ± 19.98 vs 50.98 ± 21.79, P<0.001) and quality of life scores (45.52 ± 23.95 vs 52.43 ± 26.19, P<0.001). Compared with patients treated non-invasively, patients who underwent revascularization reported improved health status over time, through 1 year of follow up (P <0.001 for all PAQ domains) ( Figure 1 ). Conclusion: Patients who underwent early revascularization had worse baseline health status but a greater improvement over 1 year of follow-up when compared with patients managed without revascularization. Summarizing real-world health status benefits following a PAD diagnosis can support preference-sensitive decisions for PAD management.

Abstract 16721: A Meta-Analysis of Early versus Delayed Revascularization Among Patients With Non-st-segment Elevation Myocardial Infarction

Introduction: Several randomized control trials (RCTs) have compared early versus delayed coronary revascularization in non-ST-segment elevation myocardial infarction (NSTEMI) and have reported contradicting results. Hypothesis: We performed a meta-analysis of all the available RCTs to date to determine the best strategy in NSTEMI. Methods: We performed a comprehensive search of PubMed, EMBASE, and Cochrane databases for all RCTs comparing an early versus delayed revascularization in NSTEMI. The primary endpoint was all-cause mortality. The secondary endpoints were re-infarction and refractory ischemia. We used the Paule-Mandel (PM) estimator of Tau with Knapp-Hartung adjustment to calculate relative risk (RR) with a 95% confidence interval (CI). Results: Thirteen RCTs were included in the final analysis. The median time between randomization and angiography ranged from 0.5 to 14 h in the early group and 18.3 to 86.0 h in the delayed group. There was no difference in mortality (5.7% vs 6.6%; RR 0.90; 95% CI 0.78-1.04; p = 0.83) (PANEL A) as well as rate of re-infarction (6.7% vs. 7.7%; RR 0.83; 95% CI 0.10-6.71; p = <0.001) (PANEL B) among both the strategy. However, early revascularization was associated with a reduction in refractory ischemia (4.8% vs 7.4%; RR 0.64; 95% CI 0.44-0.94; p=0.002) (PANEL C) Conclusions: Early revascularization for NSTEMI does not reduce the risk of mortality or re-infarction compared with delayed revascularization. Nonetheless, an early invasive approach does decrease the rate of refractory ischemia in NSTEMI.

Early revascularization in elderly with nstemi

Objective This study sought to analyse the association of early coronary intervention with poor outcomes in patients ≥75 years with NSTEMI. Methods This retrospective observational study included 7811 NSTEMI patients between the years 2005 and 2017; 2451 were older than 75 years old. We compared baseline characteristics according to GRACE risk score. Results We found that 1486 patients (60.6%) underwent early invasive coronary intervention. The long-term all-cause mortality, cardiovascular mortality and MACE differed significantly according to early coronary intervention (HR 0.67, 95% CI: 0.59–0.76; HR 0.64, 95% CI: 0.54–0.74; and HR 0.70, 95% CI: 0.63–0.78, respectively). Conclusion In elderly high-risk NSTEMI patients, early revascularization was associated with reduced all-cause and cardiovascular mortality and MACE. Funding Acknowledgement Type of funding source: None