Complete myocardial revascularization confers a larger clinical benefit when performed with state-of-the-art techniques in high-risk patients with multivessel coronary artery disease: A meta-analysis of randomized and observational studies.

OBJECTIVES: To test whether a strategy of complete revascularization (CR) as compared with incomplete myocardial revascularization (IR)-both performed with current "state-of-the-art" percutaneous coronary interventions (PCI) or coronary artery bypass graft (CABG)-would provide a clinical benefit in patients with multivessel coronary artery disease (MVCAD). BACKGROUND: The "optimal" extent of myocardial revascularization remains to be determined. METHODS: We performed a meta-analysis of studies reporting on clinical outcomes of MVCAD patients treated with CR and IR, with extensive (>80%) use of stents for PCI or arterial conduits in CABG. Relative risk (RR) and 95% confidence intervals (CIs) for all-cause mortality were assessed as primary endpoint, myocardial infarction (MI) and repeat revascularization as secondary endpoints. RESULTS: A total of 28 studies were identified, including 83,695 patients with 4.7 ± 4.3 years of follow-up. Compared with IR, CR was associated with reduced mortality (RR: 0.73; 95% CI 0.66-0.81) both after CABG (RR: 0.76; 95% CI 0.63-0.90) and PCI (RR: 0.73; 95% CI 0.64-0.82). The risks of MI (RR: 0.74; 95% CI 0.64-0.85) and repeat revascularization (RR: 0.77; 95% CI 0.66-0.88) were also lower after CR as compared with IR. Metaregression showed a significant RR reduction of MI associated with more recent publication (P = 0.021) and increasing prevalence of diabetes (P = 0.033). CONCLUSIONS: In MVCAD, as compared with IR, CR confers a clinical benefit that seems larger in cohorts of patients enrolled in more recent studies and with a higher prevalence of diabetes. © 2015 Wiley Periodicals, Inc.

Late thrombosis after double versus single drug-eluting stent in the treatment of coronary bifurcations: a meta-analysis of randomized and observational Studies.

OBJECTIVES: This study sought to hypothesize that the higher risk of myocardial infarction (MI) documented after a routine double drug-eluting stent (DES) strategy (DDS) compared with a single DES strategy (SDS) with provisional stenting in percutaneous coronary interventions (PCI) of bifurcation lesions is driven by an increased rate of DES thrombosis. BACKGROUND: The results of currently available randomized, controlled trials (RCTs) were inconclusive in the choice between SDS and DDS. Meta-analyses have shown an increased risk of MI in the DDS group, without identifying the underlying mechanism(s). METHODS: We performed a meta-analysis of 12 major (>100 patients) studies of bifurcation DES PCI: 5 RCTs and 7 nonrandomized observational studies, for a total of 6,961 patients. Random-effects models were used to calculate summary risk ratios (RRs). As a primary endpoint, we assessed the RRs and 95% confidence intervals (CIs) of definite DES thrombosis; death, MI, and target vessel revascularization (TVR) were evaluated as secondary endpoints. RESULTS: Compared with SDS, DDS had an increased risk of DES thrombosis (RR: 2.31; 95% CI: 1.33 to 4.03) and MI (RR: 1.86; 95% CI: 1.34 to 2.60). Mortality (RR: 1.18; 95% CI: 0.85 to 1.65) and TVR (RR: 1.02; 95% CI: 0.80 to 1.30) were similar. The RRs of MI and DES thrombosis were associated (p = 0.040). CONCLUSIONS: In PCI of coronary bifurcations, SDS should be the preferred approach, as DDS is associated with an increased risk of MI, likely driven by DES thrombosis.

A comparison of the diagnostic performance of the ST/HR hysteresis with cardiopulmonary stress testing parameters in detecting exercise-induced myocardial ischemia.

BACKGROUND: Because ST segment depression has limited diagnostic performance at exercise electrocardiography (ECG), ST segment depression/heart rate (ST/HR) hysteresis and cardiopulmonary exercise test (CPET)-derived parameters have been proposed as alternatives to diagnose exercise-induced myocardial ischemia. We compared the diagnostic performance of such parameters. METHODS: We studied 56 subjects (45 men, 11 women, age 59.7 ± 13.6 years) referred for suspected exercise-induced myocardial ischemia with an equivocal ECG exercise test. All subjects serially underwent CPET and a myocardial single-photon emission computerized tomography (SPECT) perfusion imaging (as the gold standard for ischemia). Maximum ST depression at peak exercise (ST-max), the ST/HR hysteresis, ΔVO2/ΔWR b-b1 slope, ΔVO2/ΔWR (aa1-bb1), VO2/HR flattening duration and other CPET parameters were derived in all subjects. RESULTS: On the basis of SPECT, 23 subjects (41%) were considered ischemic and 33 subjects (59%) non-ischemic. ST/HR hysteresis was higher (0.026 mV; 95% CI: 0.003 to 0.049 vs -0.016 mV; 95% CI: -0.031 to -0.001 mV) and ST-max was lower (-0.105 mV; 95% CI: -0.158 to -0.052 vs 0.032 mV; 95% CI: -0.001 to -0.066 mV) in ischemic vs non-ischemic subjects (P=0.004 and P=0.001, respectively). Among CPET parameters, ΔVO2/ΔWR b-b(1) slope was lower (9.4 ± 3.8) and ΔVO2/ΔWR (aa(1)-bb(1)) was higher (2.1 ± 2.6) in ischemic vs non-ischemic subjects (11.4 ± 2.3, P=0.005, and 1.1 ± 1.5, P=0.001, respectively). The ST/HR hysteresis had the highest area under the curve value, better (P<0.05) than any other parameters tested, thus showing the highest overall diagnostic performance. CONCLUSION: The ST/HR hysteresis is superior to CPET-derived parameters for detecting exercise-induced myocardial ischemia in patients with equivocal ECG exercise test results.

Defective recovery of QT dispersion predicts late cardiac mortality after percutaneous coronary intervention.

BACKGROUND: It has been suggested that corrected QT dispersion (cQTD) provides a measure of repolarisation inhomogeneity; however, the existence of a relationship between cQTD and cardiac outcomes is controversial. OBJECTIVE: To assess whether changes in cQTD following percutaneous coronary intervention (PCI) predict long-term survival. DESIGN: Prospective observational study. SETTING: Single tertiary care centre. Main outcome measures Cardiac mortality. PATIENTS: 612 patients had a 12-lead ECG recorded before and 6 h after PCI, and were followed-up for 49 ± 10 months. RESULTS: PCI was associated with a significant overall reduction of cQTD at 6 h versus baseline (p < 0.001); a reduction in cQTD occurred in 343 patients (56%). During the follow-up, 46 deaths (7.5%) were recorded, 21 of which for non-cardiac and 25 for cardiac causes. At Cox regression analysis, a reduced ΔcQTD (cQTD baseline - 6 h) was an independent predictor of cardiac mortality (HR = 1.497; 95% CI 1.081 to 2.075 for each 20 ms decrease; p = 0.015), together with age (HR = 1.672; 95% CI 1.039 to 2.691 per 10 years increase; p = 0.034), diabetes (HR = 2.622; 95% CI 1.112 to 6.184; p=0.028), peak CK-MB (HR = 1.798; 95% CI 1.063 to 3.039 per each unit increase over normal level; p = 0.029), three-vessel coronary artery disease (HR=3.626; 95% CI 1.079 to 12.187; p = 0.037) and the number of treated lesions (HR=2.066; 95% CI 1.208 to 3.532; p = 0.008). Patients in the lowest tertile of ΔcQTD and having a post-procedural increase of CK-MB had a considerably higher cardiac mortality than the remaining population (14.6 vs 2.4%, p < 0.001). CONCLUSIONS: cQTD decreases after PCI. A defective cQTD recovery, suggesting the persistence of repolarisation inhomogeneities, predicts long-term cardiac mortality.