Long-term clinical outcomes of coronary artery bypass graft surgery compared to those of percutaneous coronary intervention with second generation drug eluting stents in patients with stable angina and an isolated lesion in the proximal left anterior descending artery.

OBJECTIVES: We compared the long-term outcomes of percutaneous coronary intervention with second-generation drug-eluting stents (PCI-DES) and coronary artery bypass graft surgery (CABG) with the left internal mammary artery in stable angina patients with isolated single-vessel proximal left anterior descending artery (pLAD) disease. BACKGROUND: Long-term outcomes of second-generation PCI-DES and CABG in isolated pLAD lesions have not been extensively studied. METHODS: We included 631 PCI-DES patients and 379 CABG patients. Unadjusted and adjusted hazard ratios (HRs) were derived for major adverse cardiac events (MACEs), their components (cardiac death, nonfatal myocardial infarction [MI] not attributed to a non-target vessel, target-lesion revascularization), and patient-related outcome (PRO, composed of all-cause mortality, any MI, any revascularization). RESULTS: In the unadjusted and adjusted analyses, no significant difference was observed between the two groups at follow-up (mean:4.6 ± 2.5 years) for MACEs (HR: 1.45, 95% CI: 0.92-2.28, p = .11; HR:1.43, 95% CI: 0.91-2.26, p = .13), PRO (HR: 1.18, 95%CI: 0.86-1.61, p = .30; HR: 1.18, 95% CI: 0.86-1.62, p = .31), cardiac death (HR: 0.97, 95% CI: 0.46-2.05, p = .93; HR: 0.79, 95% CI: 0.36-1.72, p = .56) and MI (HR: 1.43, 95% CI: 0.49-4.13, p = .51; HR: 1.57, 95% CI: 0.53-4.64, p = .42). Compared with CABG, PCI-DES had a borderline significantly greater risk of repeat revascularization (HR: 1.99, 95% CI: 1.00-3.94, p = .05; HR: 1.95, 95% CI: 0.98-3.9, p = .06). Angina recurred more often after PCI (p < .001), whereas more arrhythmias developed after CABG (p = .02). PCI-DES resulted in fewer in-hospital complications (p < .001) and shorter hospitalizations (p < .001). CONCLUSIONS: The long-term clinical outcomes of second-generation PCI-DES and CABG in patients with stable angina and isolated pLAD disease were comparable.

The prognostic value of CHA2DS2-VASc and GRACE risk scores in patients with ACS.

OBJECTIVE: Cardiovascular diseases are the first cause of death in western societies. Therapeutic interventions in the individual patient should be guided by the so-called ischemic risk of this patient. PURPOSE: The aim of the study was to study the ischemic prognostic scores GRACE and CHA2DS2-VASc, in patients underwent angioplasty to highlight which best predicts better the ischemic risk. METHODS: Consecutives patients who underwent Percutaneous Coronary Intervention (PCI) due to Acute Coronary Disease, or elective PCI in one centre in Athens, Greece, where included in the study. The GRACE score and the CHA2DS2-VASc score were calculated. RESULTS: 667 patients participated in the study with an average age of 61 ± 11 years and were followed-up for 2 years. The GRACE score and its predicted incidence at 3 years, was compared to the CHA2DS2-VASc score. CHA2DS2-VASc score was able to show a marginally better prognosis of future ischemic events, with an AUC of 0.624 vs 0.608 of the GRACE score. CONCLUSIONS: In our study, The CHA2DS2-VASc score managed to predict, marginally better, the appearance of MACCE over GRACE, in patients with angioplasty.

Late differences in outcomes of patients with stable angina and an isolated lesion in the proximal left anterior descending artery treated with new-generation drug-eluting stents.

BACKGROUND: New-generation drug-eluting stents have demonstrated the mid-term efficacy and safety, but possible differences between stents may emerge in a long-term period. We compared long-term outcomes of patients with chronic stable angina and an isolated de-novo lesion in the proximal left anterior descending artery that underwent percutaneous coronary intervention with Endeavor-zotarolimus eluting stents (E-ZES) and everolimus eluting stents (EES). METHODS: We prospectively enrolled 600 patients. Of these, 180 underwent E-ZES and 420 underwent EES implantation. Clinical follow-up was performed up to 7 years (median follow-up 61 months). The evaluated clinical outcomes were Target Lesion Failure (TLF), a composite of cardiac death, myocardial infarction and Target Lesion Revascularization (TLR), the Patient-Related Outcome (PRO) and stent thrombosis. Differences between groups evaluated with the Kaplan-Meier method and possible independent predictors with Cox proportional hazard regression. RESULTS: At 5 years, the cumulative probability for outcomes was: TLF: 13.8% versus 7.5%, p=0.025, cardiac death: 3.1% versus 2.5%, p=0.937, myocardial infarction: 1.2% versus 1.8%, p=0.829, TLR: 10% versus 3.3%, p=0.003, PRO: 19.6% versus 13.8%, p=0.528, ST: 2.5% versus 2.7%, p=0.965, for E-ZES and EES respectively. Differences between stents increased after 30 months. In multivariate analysis predictors of TLF adjusted for stent type were Diabetes mellitus and estimated Glomerular Filtration Rate (eGFR). CONCLUSION: Both stents provided a favorable safety profile, with EES demonstrating better effectiveness. There was a late emergence in difference of endpoints after 30 months. Diabetes mellitus and eGFR predicted TLF.

The impact of new generation drug-eluting stent implantation on patients with chronic kidney disease and a single lesion in the proximal segment of the left anterior descending artery.

INTRODUCTION: The impact of drug-eluting stents (DES) has not been extensively investigated in patients with moderate to severe renal dysfunction, as these patients are consistently excluded from randomised studies. We sought to assess prospectively the effectiveness and safety of the new-generation DES in patients with moderate chronic kidney disease (CKD) and an isolated de novo lesion in the proximal segment of the left anterior descending artery (pLAD). METHODS: We evaluated 400 consecutive patients with a pLAD lesion. There were 96 patients with moderate CKD (estimated glomerular filtration rate 59 ml/min/1.73 m2) and 304 without CKD. Major adverse cardiac events (MACE) were defined as death, non-fatal myocardial infarction and target lesion revascularisation (TLR). Clinical or telephone follow up was performed. RESULTS: There was a significantly higher incidence of mortality in patients with CKD (n=4) as compared with non-CKD (n=2) (4.16% versus 0.65%, respectively, p=0.03). The rate of non-fatal myocardial infarction was similar in the 2 cohorts (p=0.59), as was the TLR rate (p=0.99). Overall, there were no significant differences regarding MACE between the 2 groups of patients (p=0.19) during the 13.62 ± 6.22 month follow-up period. The rate of angiographic stent thrombosis was 2.08% in the CKD group versus 0.98% in the non-CKD group (p=0.59). CONCLUSIONS: New generation DES implantation in patients with CKD and a pLAD lesion is effective and safe, with rates of TLR and stent thrombosis comparable to those in patients with normal renal function. However, the higher mortality in patients with CKD needs further evaluation.

Everolimus- and zotarolimus-eluting stents for bare metal stent in-stent restenosis treatment: a prospective study.

BACKGROUND: Treatment of in-stent restenosis (ISR) is a challenging clinical problem. Recent studies have verified the safety and efficacy of first-generation DES for the treatment of ISR. The safety and effectiveness of new-generation drug-eluting stents (nDES) for ISR has not been previously investigated. The aim of the present study was to prospectively evaluate the clinical outcomes after treatment with nDES implantation in patients with bare metal stent (BMS) ISR. METHODS: Consecutive patients with ISR after BMS implantation were included. Primary end-point was a major adverse cardiac event (MACE), defined as death, myocardial infarction (MI), or target vessel revascularization (TVR). The incidence of stent thrombosis was also evaluated. RESULTS: A total of 46 consecutive patients were enrolled for the treatment of ISR, 23 patients from ZES and 23 from EES group. There were two (8.7%) cases of TVR in ZES cohort due to proliferative ISR at 6 and 7 months after DES implantation, and none in EES. One (4.3%) patient underwent percutaneous coronary intervention and the other (4.3%) was treated surgically. Neither acute nor subacute thrombosis was observed during the 13.3+/-6.3 months follow-up period. In all other patients, stress test was negative for ischemia at 6 months. CONCLUSIONS: In this prospective study, we showed that direct nDES implantation is highly effective for ISR and seems to be a promising management for the treatment of ISR.

A preliminary experience report: Drug-eluting stents versus coronary artery bypass surgery in patients with a single lesion in the proximal left anterior descending artery suffering from diabetes mellitus and chronic stable angina.

INTRODUCTION: Treatment of lesions located in the proximal segment of the left anterior descending artery (pLAD), either with coronary artery bypass grafting (CABG) or percutaneous coronary intervention, in patients with diabetes mellitus has been associated with an unfavourable outcome. The aim of the present study was to compare the long-term clinical outcome of drug-eluting stents (DES) vs. CABG with a left internal mammary artery (LIMA) graft in patients with a pLAD lesion who suffered from chronic stable angina and diabetes mellitus. METHODS: We studied 77 consecutive patients suffering from chronic stable angina, diabetes mellitus, and with an isolated pLAD lesion. Thirty-nine patients underwent DES implantation and 38 LIMA grafting. Primary endpoints were the occurrence of major adverse cardiac events, defined as death, myocardial infarction, and target vessel revascularisation. Secondary endpoints included the length of stay in hospital, in-hospital complications, and the recurrence of chest pain. RESULTS: More in-hospital complications were observed in the CABG group than in the DES group. The mean duration of hospitalisation after CABG was 7.76 +/- 2.82 days vs. 1.17 +/- 1.15 days after DES. The mean follow-up period was 19.7 +/- 6.3 months for the DES group and 19.7 +/- 7.4 months for the surgical group. The incidence of major adverse cardiac events was similar in the two groups. There were two re-interventions in the DES group and none in the surgical group. Recurrent angina occurred in 2 patients in the DES group and 3 patients in the CABG group. CONCLUSIONS: The present study demonstrates that patients with diabetes mellitus, chronic stable angina, and single vessel disease in the pLAD have an excellent long-term outcome with both DES implantation and LIMA anastomosis. The surgical approach, however, was associated with more in-hospital complications and a longer hospitalisation.

Drug eluting stents versus coronary artery bypass surgery in patients with isolated proximal lesion in left anterior descending artery suffering from chronic stable angina.

OBJECTIVE: To compare the efficacy of drug eluting stents (DES) compared with bypass surgery (CABG) with left internal mammary artery (LIMA) in patients with single vessel disease suffering from chronic stable angina. BACKGROUND: There are a limited number of studies investigating this group of patients. METHODS: We included 257 consecutive patients with isolated lesion in the proximal segment of left anterior descending artery (LAD). All patients suffered from chronic stable angina or from stress-induced ischemia. Of 257 patients, 147 underwent DES implantation and 110 CABG with LIMA. All patients were followed-up clinically for major adverse cardiac events. RESULTS: The baseline demographic and angiographic characteristics were similar between the two groups. In the DES group we used sirolimus-, paclitaxel-, and ABT-578-eluting stents. The mean duration of hospitalization after CABG was 7.86 +/- 3.84 days vs. 1.02 +/- 0.19 days after PCI (P < 0.01). The incidence of MACE was 2.72% in the DES and 2.72% in the surgical group during a mean follow-up period of 18.71 +/- 6.27 months for PCI and 18.70 +/- 7.31 months for CABG (P = 0.99). There was one cardiac related death in the DES group and two in the surgical group (P = 0.58). There were three reinterventions in the DES group versus none in the surgical group (P = 0.26). Recurrence of angina was observed in 4.08% of pts in the DES group versus 6.36% in the CABG group (P = 0.57). CONCLUSIONS: The present study demonstrated that patients suffering from chronic stable angina with isolated lesion in the proximal segment of LAD have excellent long-term outcome in both surgical and DES treatment.