Does Gender Affect the Outcomes of Myocardial Revascularization for Left-Main Coronary Artery Disease?

Currently, gender is not considered in the choice of the revascularization strategy for patients with unprotected left main coronary artery (ULMCA) disease. This study analyzed the effect of gender on the outcomes of percutaneous coronary intervention (PCI) vs coronary artery bypass grafting (CABG) in patients with ULMCA disease. Females who had PCI (n = 328) were compared with females who had CABG (n = 132) and PCI in males (n = 894) was compared with CABG (n = 784). Females with CABG had higher overall hospital mortality and major adverse cardiovascular events (MACE) than females with PCI. Male patients with CABG had higher MACE; however, mortality did not differ between males with CABG vs PCI. In female patients, follow-up mortality was significantly higher in CABG patients, and target lesion revascularization was higher in patients with PCI. Male patients had no difference in mortality and MACE between groups; however, MI was higher with CABG, and congestive heart failure was higher with PCI. In conclusion, women with ULMCA disease treated with PCI could have better survival with lower MACE compared with CABG. These differences were not evident in males treated with either CABG or PCI. PCI could be the preferred revascularization strategy in women with ULMCA disease.

Single Versus Dual Antiplatelet Therapy After Coronary Artery Bypass Grafting for Unprotected Left-Main Coronary Disease.

BACKGROUND: The use of dual antiplatelet therapy (DAPT) after coronary revascularization for left-main disease is still debated. The study aimed to characterize patients who received dual versus single antiplatelet therapy (SAPT) after coronary artery bypass grafting (CABG) for unprotected left-main disease and compare the outcomes of those patients. RESULTS: This multicenter retrospective cohort study included 551 patients who were grouped into 2 groups: patients who received SAPT (n = 150) and those who received DAPT (n = 401). There were no differences in age ( P = 0.451), gender ( P = 0.063), smoking ( P = 0.941), diabetes mellitus ( P = 0.773), history of myocardial infarction ( P = 0.709), chronic kidney disease ( P = 0.615), atrial fibrillation ( P = 0.306), or cerebrovascular accident ( P = 0.550) between patients who received SAPT versus DAPT. DAPTs were more commonly used in patients with acute coronary syndrome [87 (58%) vs. 273 (68.08%); P = 0.027], after off-pump CABG [12 (8%) vs. 73 (18.2%); P = 0.003] and in patients with radial artery grafts [1 (0.67%) vs. 32 (7.98%); P < 0.001]. While SAPTs were more commonly used in patients with low ejection fraction [55 (36.67%) vs. 61 (15.21%); P < 0.001] and in patients with postoperative acute kidney injury [27 (18%) vs. 37 (9.23%); P = 0.004]. The attributed treatment effect of DAPT for follow-up major adverse cerebrovascular and cardiac events was not significantly different from that of SAPT [ß, -2.08 (95% confidence interval (CI), -20.8-16.7); P = 0.828]. The attributed treatment effect of DAPT on follow-up all-cause mortality was not significantly different from that of SAPT [ß, 4.12 (CI, -11.1-19.32); P = 0.595]. There was no difference in bleeding between groups ( P = 0.666). CONCLUSIONS: DAPTs were more commonly used in patients with acute coronary syndrome, after off-pump CABG, and with radial artery grafts. SAPTs were more commonly used in patients with low ejection fraction and acute kidney injury. Patients on DAPT after CABG for left-main disease had comparable major adverse cerebrovascular and cardiac events and survival to patients on SAPT, with no difference in bleeding events.

Percutaneous coronary intervention vs. coronary artery bypass grafting in emergency and non-emergency unprotected left-main revascularization.

BACKGROUND: The optimal revascularization strategy in patients with left main coronary artery (LMCA) disease in the emergency setting is still controversial. Thus, we aimed to compare the outcomes of percutaneous coronary interventions (PCI) vs. coronary artery bypass grafting (CABG) in patients with and without emergent LMCA disease. METHODS: This retrospective cohort study included 2138 patients recruited from 14 centers between 2015 and 2019. We compared patients with emergent LMCA revascularization who underwent PCI (n = 264) to patients who underwent CABG (n = 196) and patients with non-emergent LMCA revascularization with PCI (n = 958) to those who underwent CABG (n = 720). The study outcomes were in-hospital and follow-up all-cause mortality and major adverse cardiovascular and cerebrovascular events (MACCE). RESULTS: Emergency PCI patients were older and had a significantly higher prevalence of chronic kidney disease, lower ejection fraction, and higher EuroSCORE than CABG patients. CABG patients had significantly higher SYNTAX scores, multivessel disease, and ostial lesions. In patients presenting with arrest, PCI had significantly lower MACCE (P = 0.017) and in-hospital mortality (P = 0.016) than CABG. In non-emergent revascularization, PCI was associated with lower MACCE in patients with low (P = 0.015) and intermediate (P < 0.001) EuroSCORE. PCI was associated with lower MACCE in patients with low (P = 0.002) and intermediate (P = 0.008) SYNTAX scores. In non-emergent revascularization, PCI was associated with reduced hospital mortality in patients with intermediate (P = 0.001) and high (P = 0.002) EuroSCORE compared to CABG. PCI was associated with lower hospital mortality in patients with low (P = 0.031) and intermediate (P = 0.001) SYNTAX scores. At a median follow-up time of 20 months (IQR: 10-37), emergency PCI had lower MACCE compared to CABG [HR: 0.30 (95% CI 0.14-0.66), P < 0.003], with no significant difference in all-cause mortality between emergency PCI and CABG [HR: 1.18 (95% CI 0.23-6.08), P = 0.845]. CONCLUSIONS: PCI could be advantageous over CABG in revascularizing LMCA disease in emergencies. PCI could be preferred for revascularization of non-emergent LMCA in patients with intermediate EuroSCORE and low and intermediate SYNTAX scores.

Left Main Coronary Artery Revascularization in Patients with Impaired Renal Function: Percutaneous Coronary Intervention versus Coronary Artery Bypass Grafting.

INTRODUCTION: The evidence about the optimal revascularization strategy in patients with left main coronary artery (LMCA) disease and impaired renal function is limited. Thus, we aimed to compare the outcomes of LMCA disease revascularization (percutaneous coronary intervention [PCI] vs. coronary artery bypass grafting [CABG]) in patients with and without impaired renal function. METHODS: This retrospective cohort study included 2,138 patients recruited from 14 centers between 2015 and 2,019. We compared patients with impaired renal function who had PCI (n= 316) to those who had CABG (n = 121) and compared patients with normal renal function who had PCI (n = 906) to those who had CABG (n = 795). The study outcomes were in-hospital and follow-up major adverse cardiovascular and cerebrovascular events (MACCE). RESULTS: Multivariable logistic regression analysis showed that the risk of in-hospital MACCE was significantly higher in CABG compared to PCI in patients with impaired renal function (odds ratio [OR]: 8.13 [95% CI: 4.19-15.76], p < 0.001) and normal renal function (OR: 2.59 [95% CI: 1.79-3.73]; p < 0.001). There were no differences in follow-up MACCE between CABG and PCI in patients with impaired renal function (HR: 1.14 [95% CI: 0.71-1.81], p = 0.585) and normal renal function (HR: 1.12 [0.90-1.39], p = 0.312). CONCLUSIONS: PCI could have an advantage over CABG in revascularization of LMCA disease in patients with impaired renal function regarding in-hospital MACCE. The follow-up MACCE was comparable between PCI and CABG in patients with impaired and normal renal function.

National Heart Center/Saudi Heart Association 2023 Guidelines on the Management of Hypertension.

Background: Hypertension is a highly prevalent disease in Saudi Arabia with poor control rates. Updated guidelines are needed to guide the management of hypertension and improve treatment outcomes. Methodology: A panel of experts representing the National Heart Center (NHC) and the Saudi Heart Association (SHA) reviewed existing evidence and formulated guidance relevant to the local population, clinical practice and the healthcare system. The recommendations were reviewed to ensure scientific and medical accuracy. Recommendations: Hypertension was defined and a new classification was proposed as relevant to the Saudi population. Recommendations on diagnosis, clinical evaluation, cardiovascular assessment were detailed, along with guidance on measurement modalities and screening/follow-up. Non-pharmacological management is the first line of hypertension treatment. Pharmacological therapy should be used appropriately as needed. Treatment priority is to control blood pressure regardless of the drug class used. The choice of treatment should be tailored to the patient profile in order to achieve treatment targets and ensure patient compliance. Recommendations were provided on pharmacological options available in Saudi Arabia, as well as guidance on the treatment of special conditions. Conclusion: Hypertension management should be based on appropriate screening, timely diagnosis and lifestyle changes supplemented with pharmacological therapy, as needed. Clinical management should be individualized, and careful consideration should be given to special conditions and patient groups.

Outcomes of Left Main Revascularization in Patients with Anemia: Gulf Left Main Registry.

INTRODUCTION: The aim of this study was to evaluate the effects of baseline anemia and anemia following revascularization on outcomes in patients with unprotected left main coronary artery (ULMCA) disease. METHODS: This was a retrospective, multicenter, observational study conducted between January 2015 and December 2019. The data on patients with ULMCA who underwent revascularization through percutaneous coronary intervention (PCI) or coronary artery bypass graft (CABG) were stratified by the hemoglobin level at baseline into anemic and non-anemic groups to compare in-hospital events. The pre-discharge hemoglobin following revascularization was categorized into very low (<80 g/L for men and women), low (≥80 and ≤119 g/L for women and ≤129 g/L for men), and normal (≥130 g/L for men and ≥120 g/L for women) to assess impact on follow-up outcomes. RESULTS: A total of 2,138 patients were included, 796 (37.2%) of whom had anemia at baseline. A total of 319 developed anemia after revascularization and moved from being non-anemic at baseline to anemic at discharge. There was no difference in hospital major adverse cardiac and cerebrovascular event (MACCE) and mortality between CABG and PCI in anemic patients. At a median follow-up time of 20 months (interquartile range [IQR]: 27), patients with pre-discharge anemia who underwent PCI had a higher incidence of congestive heart failure (CHF) (p < 0.0001), and those who underwent CABG had significantly higher follow-up mortality (HR: 9.85 (95% CI: 2.53-38.43), p = 0.001). CONCLUSION: In this Gulf LM study, baseline anemia had no impact upon in-hospital MACCE and total mortality following revascularization (PCI or CABG). However, pre-discharge anemia is associated with worse outcomes after ULMCA disease revascularization, with significantly higher all-cause mortality in patients who had CABG, and a higher incidence of CHF in PCI patients, at a median follow-up time of 20 months (IQR: 27).

One Versus Two Stents Strategies for Unprotected Left Main Intervention: Gulf Left Main Registry.

The optimal stenting strategy for unprotected left main coronary artery (ULMCA) disease remains debated. This retrospective observational study (Gulf Left Main Registry) analyzed the outcomes of 1 vs 2 stents in patients with unprotected left main percutaneous coronary intervention (PCI). Overall, 1222 patients were evaluated; 173 had 1 stent and 1049 had 2 stents. The 2-stent group was older with more comorbidities, higher mean SYNTAX scores, and more distal bifurcation lesions. In the 1-stent group, in-hospital events were significant for major bleeding, and better mean creatinine clearance. At median follow-up of 20 months, the 1-stent group was more likely to have target lesion revascularization (TLR). Total mortality was numerically lower in the 1-stent group (.00% vs 2.10%); however, this was not statistically significant (P=.068). Our analysis demonstrates the benefits of a 2-stent approach for ULMCA patients with high SYNTAX scores and lesions in both major side branches, while the potential benefit of a 1-stent approach for less complex ULMCA was also observed. Further studies with longer follow-up are needed to definitively demonstrate the optimal approach.

Impact of left ventricular ejection fraction on outcomes after left main revascularization: g-LM Registry.

AIMS: The impact of left ventricular dysfunction on clinical outcomes following revascularization is not well established in patients with unprotected left main coronary artery disease (ULMCA). In this study, we evaluated the impact of left ventricular ejection fraction (LVEF) on clinical outcomes of patients with ULMCA requiring revascularization with percutaneous coronary intervention (PCI) compared with coronary artery bypass graft (CABG). METHODS: The details of the design, methods, end points, and relevant definitions are outlined in the Gulf Left Main Registry: a retrospective, observational study conducted between January 2015 and December 2019 across 14 centres in 3 Gulf countries. In this study, the data on patients with ULMCA who underwent revascularization through PCI or CABG were stratified by LVEF into three main subgroups; low (l-LVEF <40%), mid-range (m-LVEF 40-49%), and preserved (p-LVEF ≥50%). Primary outcomes were hospital major adverse cardiovascular and cerebrovascular events (MACCE) and mortality and follow-up MACCE and mortality. RESULTS: A total of 2137 patients were included; 1221 underwent PCI and 916 had CABG. During hospitalization, MACCE was significantly higher in patients with l-LVEF [(10.10%), P = 0.005] and m-LVEF [(10.80%), P = 0.009], whereas total mortality was higher in patients with m-LVEF [(7.40%), P = 0.009] and p-LVEF [(7.10%), P = 0.045] who underwent CABG. There was no mortality difference between groups in patients with l-LVEF. At a median follow-up of 15 months, there was no difference in MACCE and total mortality between patients who underwent CABG or PCI with p-LVEF and m-LVEF. CONCLUSION: CABG was associated with higher in-hospital events. Hospital mortality in patients with l-LVEF was comparable between CABG and PCI. At 15 months' follow-up, PCI could have an advantage in decreasing MACCE in patients with l-LVEF.

Outcomes of Myocardial Revascularization in Diabetic Patients With Left Main Coronary Artery Disease: A Multicenter Observational Study From Three Gulf Countries.

BACKGROUND: Real-world data for managing patients with diabetes and left main coronary artery (LMCA) disease are scarce. We compared percutaneous coronary intervention (PCI) outcomes versus coronary artery bypass grafting (CABG) in diabetes and LMCA disease patients. METHODS: We retrospectively studied patients with LMCA presented to 14 centers from 2015 to 2019. The study included 2138 patients with unprotected LMCA disease; 1468 (68.7 %) had diabetes. Patients were grouped into; diabetes with PCI (n = 804) or CABG (n = 664) and non-diabetes with PCI (n = 418) or CABG (n = 252). RESULTS: In diabetes, cardiac (34 (5.1 %) vs. 22 (2.7 %); P = 0.016), non-cardiac (13 (2 %) vs. 6 (0.7 %); P = 0.027) and total hospital mortality (47 (7.1 %) vs. 28 (3.5 %); P = 0.0019), myocardial infarction (45 (6.8 %) vs. 11 (1.4 %); P = 0.001), cerebrovascular events (25 (3.8 %) vs. 12 (1.5 %); P = 0.005) and minor bleeding (65 (9.8 %) vs. 50 (6.2 %); P = 0.006) were significantly higher in CABG patients compared to PCI; respectively. The median follow-up time was 20 (10-37) months. In diabetes, total mortality was higher in CABG (P = 0.001) while congestive heart failure was higher in PCI (P = 0.001). There were no differences in major adverse cerebrovascular events and target lesion revascularization between PCI and CABG. Predictors of mortality in diabetes were high anatomical SYNTAX, peripheral arterial disease, chronic kidney disease, and cardiogenic shock. CONCLUSIONS: In this multicenter retrospective study, we found no significant difference in clinical outcomes during the short-term follow-up between PCI with second-generation DES and CABG except for lower total mortality and a higher rate of congestive heart failure in PCI group of patients. Randomized trials to characterize patients who could benefit from each treatment option are needed.

Unprotected Left Main Revascularization in the Setting of Non-coronary Atherosclerosis: Gulf Left Main Registry.

Coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI) in revascularization of left main coronary artery (LMCA) disease has been evaluated in previous studies. However, there has been minimal study of the relationship between co-existing non-coronary atherosclerosis (NCA) and LMCA disease revascularization. We aim to examine this relationship. The Gulf-LM study is a retrospective analysis of unprotected LMCA revascularization cases undergoing PCI with second generation drug-eluting stent vs CABG across 14 centers within 3 Gulf countries between January 2015 and December 2019. A total of 2138 patients were included, 381 with coexisting NCA and 1757 without. Outcomes examined included major adverse cardiovascular and cerebrovascular events (MACCE), cardiac and non-cardiac death, and all bleeding. In patients with NCA, preexisting myocardial infarction and congestive heart failure were more common, with PCI being the most common revascularization strategy. A statistically significant reduction in in-hospital MACCE and all bleeding was noted in patients with NCA undergoing PCI as compared to CABG. At a median follow-up of 15 months, MACCE and major bleeding outcomes continued to favor the PCI group, though no such difference was identified between revascularization strategies in patients without NCA.In this multicenter retrospective study of patients with and without NCA who require revascularization (PCI and CABG) for unprotected LMCA disease, PCI demonstrated a better clinical outcome in MACCE both in-hospital and during the short-term follow-up in patients with NCA. However, no such difference was observed in patients without NCA.

Percutaneous Coronary Intervention Vs Coronary Artery Bypass Surgery for Unprotected Left Main Coronary Disease: G-LM Registry.

Coronary artery bypass surgery (CABG) has been the standard of care for revascularization for patients with obstructive unprotected left main coronary disease (ULMCA). There have been multiple randomized and registry data demonstrating the technical and clinical efficacy of PCI in certain patients with ULMCA. The purpose of this study is to evaluate clinical outcomes of ULMCA PCI as compared to CABG in patients requiring revascularization in three Gulf countries. All ULMCA cases treated by PCI with DES versus CABG were retrospectively identified from 14 centers in 3 Arab Gulf countries (KSA, UAE, and Bahrain) from January 2015 to December 2019. In total, 2138 patients were included: 1222 were treated with PCI versus 916 with CABG. Patients undergoing PCI were older, and had higher comorbidities and mean European System for Cardiac Operative Risk Evaluation (EuroSCORE). Aborted cardiac arrest and cardiogenic shock were reported more in the PCI group at hospital presentation. In addition, lower ejection fractions were reported in the PCI group. In hospital mortality and major adverse cardiovascular and cerebrovascular events (MACCE) occurred more in patients undergoing CABG than PCI. At median follow-up of 15 months (interquartile range, 30), no difference was observed in freedom from revascularization, MACCE, or total mortality between those treated with PCI and CABG. While findings are similar to Western data registries, continued follow-up will be needed to ascertain whether this pattern continues into latter years.

STEMI and COVID-19 Pandemic in Saudi Arabia.

The COVID-19 pandemic had significant impact on health care worldwide which has led to a reduction in all elective admissions and management of patients through virtual care. The purpose of this study is to assess changes in STEMI volumes, door to reperfusion, and the time from the onset of symptoms until reperfusion therapy, and in-hospital events between the pre-COVID-19 (PC) and after COVID-19 (AC) period. All acute ST-segment elevation myocardial infarction (STEMI) cases were retrospectively identified from 16 centers in the Kingdom of Saudi Arabia during the COVID-19 period from January 01 to April 30, 2020. These cases were compared to a pre-COVID period from January 01 to April 30, 2018 and 2019. One thousand seven hundred and eighty-five patients with a mean age 56.3 (SD ± 12.4) years, 88.3% were male. During COVID-19 Pandemic the total STEMI volumes was reduced (28%, n = 500), STEMI volumes for those treated with reperfusion therapy was reduced too (27.6%, n= 450). Door to balloon time < 90 minutes was achieved in (73.1%, no = 307) during 2020. Timing from the onset of symptoms to the balloon of more than 12 hours was higher during 2020 comparing to pre-COVID 19 years (17.2% vs <3%, respectively). There were no differences between the AC and PC period with respect to in-hospital events and the length of hospital stay. There was a reduction in the STEMI volumes during 2020. Our data reflected the standard of care for STEMI patients continued during the COVID-19 pandemic while demonstrating patients delayed presenting to the hospital.

Practical perspectives on the use of non-vitamin K antagonist oral anticoagulants for stroke prevention in patients with nonvalvular atrial fibrillation: A view from the Middle East and North Africa.

Clinical guidelines for the prevention of stroke in patients with nonvalvular atrial fibrillation (NVAF) are available from several international cardiology associations. Patients with NVAF in the Middle East and North Africa (MENA) region present unique challenges and opportunities related to differences in geography, practice patterns, and patient demographics that are as yet unaddressed in practice guidelines. This review aims to offer a practical perspective on the management of NVAF in patients in MENA and draws on evidence-based guidelines as well as real-world evidence and expert opinion. The literature was searched for relevant original research articles, systematic reviews, meta-analyses, and guideline recommendations addressing the prevention of stroke in patients with NVAF with a focus on issues relevant to the MENA region. Guideline recommendations, best practices, and expert opinion were discussed and agreed on by a working group consisting of cardiologists from across the MENA region. The incidence of stroke secondary to atrial fibrillation in patients across the MENA region is higher than rates reported globally, and this might be attributed to a higher incidence of vascular risk factors and underuse of anticoagulants in patients in the MENA. The available evidence supports the established role of non-vitamin K antagonist oral anticoagulants (NOACs) in the prevention of stroke in patients with NVAF. There is a consistent body of clinical trial and real-world evidence supporting their efficacy for stroke prevention in NVAF, with more favorable bleeding risk profiles relative to vitamin K antagonists, such that guidelines now recommend the use of NOACs in preference over vitamin K antagonists. There are important opportunities to improve the management of NVAF outcomes for patients with NVAF by applying evidence-based guidelines for stroke prevention. Growing experience with NOACs in the MENA region will help guide patient selection and elucidate optimal dosing strategies to maximize the clinical benefits of the NOACs.

Evaluation of ISO EN 13606 as a result of its implementation in XML.

The five parts of the ISO EN 13606 standard define a means by which health-care records can be exchanged between computer systems. Starting within the European standardisation process, it has now become internationally ratified in ISO. However, ISO standards do not require that a reference implementation be provided, and in order for ISO EN 13606 to deliver the expected benefits, it must be provided not as a document, but as an operational system that is not vendor specific. This article describes the evolution of an Extensible Markup Language (XML) Schema through three iterations, each of which emphasised one particular approach to delivering an executable equivalent to the printed standard. Developing these operational versions and incorporating feedback from users of these demonstrated where implementation compromises were needed and exposed defects in the standard. These are discussed herein. They may require a future technical revision to ISO EN 13606 to resolve the issues identified.