Midterm Outcome After Septal Myectomy and Medical Therapy in Mildly Symptomatic Patients With Hypertrophic Obstructive Cardiomyopathy.

Objective: The purpose of this study was mainly to determine the midterm outcome of septal myectomy (SM) and medical therapy (MT) in mildly symptomatic patients (NYHA class II) with hypertrophic obstructive cardiomyopathy (HOCM). Methods: The study cohort consisted of 184 mildly symptomatic patients with HOCM evaluated in Beijing Anzhen Hospital, Capital Medical University between March 2001 and December 2017, including 82 patients in the SM group and 102 patients in the MT group. Overall survival and HCM-related survival were mainly observed. Results: The average follow-up time was 5.0 years. Compared to patients accepting MT, patients treated with SM were associated with comparable overall survival (96.5% and 93.1% vs. 92.9% and 83.0% at 5 and 10 years, respectively; P = 0.197) and HCM-related survival (98.7% and 98.7% vs. 94.2% and 86.1% at 5 and 10 years, respectively; P = 0.063). However, compared to MT, SM was superior at improvement of NYHA class (1.3 ± 0.6 vs. 2.1 ± 0.5, P < 0.001) and mean reduction of resting left ventricular outflow (LVOT) gradient (78.5 ± 18.6% vs. 28.3 ± 18.4%, P < 0.001). Multivariate analysis suggested that resting LVOT gradient in the last clinical examination was an independent predictor of all-cause mortality (HR = 1.017, 95%CI: 1.000-1.034, P = 0.045) and HCM-related mortality (HR = 1.024, 95%CI: 1.005-1.043, P = 0.012) in the entire cohort. Conclusion: Compared with MT, SM had comparable overall survival and HCM-related survival in mildly symptomatic HOCM patients, but SM had advantages on improving clinical symptoms and reducing resting LVOT gradient. Resting LVOT gradient in the last clinical examination was an independent predictor of all-cause mortality and HCM-related mortality.

Outcome of alcohol septal ablation in mildly symptomatic patients with hypertrophic obstructive cardiomyopathy: A comparison with medical therapy.

OBJECTIVE: The aim of this study was primarily to determine efficacy after alcohol septal ablation (ASA) in mildly symptomatic patients (NYHA class II) with hypertrophic obstructive cardiomyopathy (HOCM), as compared to medical therapy. METHODS: This retrospective study included 163 mildly symptomatic patients with HOCM evaluated in Beijing Anzhen Hospital between March 2001 and August 2019, consisting of the medical group (n = 105) and the ASA group (n = 58). All-cause mortality and HCM-related death were mainly observed. RESULTS: Follow-up was completed in 161 patients and the median follow-up was 6.0 years. Compared to medically treated patients, patients post-ASA had comparable survival free of all-cause mortality (98.3% and 95.1% vs. 93.0% and 83.1% at 5 and 10 years, respectively; p = 0.374). Survival free of HCM-related death was also similar between ASA and medical groups (98.3% and 95.1% vs. 94.3% and 86.2% at 5 and 10 years, respectively; p = 0.608). However, compared to medical therapy, ASA had advantages on the improvement of NYHA class (1.4 ± 0.6 vs. 2.1 ± 0.5, p = .000) and lower occurrence of new-onset atrial fibrillation (AF) (7.8% vs. 20.4%, p = .048). Multivariate analysis demonstrated that resting LVOT gradient at the last clinical check-up was an independent predictor of all-cause mortality (HR = 1.021, 95%CI 1.002-1.040, p = .027). CONCLUSION: This registry suggests that mildly symptomatic patients with HOCM treated with ASA have comparable survival to that of medically treated patients, with the improvement of NYHA class and lower occurrence of new-onset AF. All-cause mortality is independently associated with resting LVOT gradient at the last clinical check-up.

Left ventricular systolic dysfunction in patients with unprotected left main coronary artery disease.

BACKGROUND: The optimal coronary revascularization strategy for patients with unprotected left main coronary artery (ULMCA) disease and left ventricular systolic dysfunction (LVSD) remains uncertain. The purpose of this study was to evaluate the clinical outcomes after percutaneous coronary intervention (PCI) with a drug-eluting stent (DES) versus coronary artery bypass grafting (CABG) in patients with ULMCA disease with or without LVSD. METHODS: A total of 984 patients with ULMCA disease who received a DES (n = 511) or underwent CABG (n = 473) were included in this study. We retrospectively analyzed the clinical parameters and outcomes of ULMCA disease patients with different left ventricular ejection fraction levels. RESULTS: There were no significant differences in major adverse cardiac and cerebral events, all-cause death, cardiac death, myocardial infarction, or stroke between the CABG and DES groups with or without LVSD. The rate of target vessel revascularization was significantly higher with DES compared with CABG in patients without LVSD; however, the difference was not significant between the mild LVSD and severe LVSD groups. CONCLUSION: For patients with ULMCA disease and LVSD, there was no significant difference between DES and CABG in terms of efficacy and safety. Treatment with DES was an acceptable alternative to CABG.

Twelve-year outcomes after revascularization for ostial/shaft lesions in unprotected left main coronary artery.

OBJECTIVE: To evaluate a very long-term clinical outcomes of patients treated with coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI) with drug-eluting stents (DES) for ostial/shaft lesions in unprotected left main coronary artery (ULMCA). METHODS & RESULTS: A total of 472 patients with isolated ostial/shaft lesions in ULMCA were enrolled, who received DES implantation or underwent CABG between January 2003 and July 2009 in Beijing Anzhen Hospital. The major endpoints of this study were death, repeat revascularization, non-procedural myocardial infarction (MI) and stroke. The median follow-up was twelve years (interquartile range: 9.4-14.0 years) in the overall patients. There were no significant differences of incidence of death (23.3% vs. 25.6%, P = 0.227), repeat revascularization (27.3% vs. 28.4%, P = 0.423), non-procedural MI (20.0% vs. 14.5%, P = 0.561), and stroke (6.1% vs. 9.3%, P = 0.255) between PCI and CABG groups before multivariate adjusting. After adjusting covariates with multivariate Cox hazard regression model, there were still no significant differences between PCI and CABG groups. CONCLUSIONS: During the median follow-up of twelve years, we found that PCI with DES was as effective and safe as CABG in patients with left main ostial/shaft lesion in this observational study.

Growth differentiation factor-15 is a prognostic marker in patients with intermediate coronary artery disease.

BACKGROUND: Growth differentiation factor-15 (GDF-15) is involved in multiple processes that are associated with coronary artery disease (CAD). However, little is known about the association between GDF-15 and the future ischemic events in patients with intermediate CAD. This study was conducted to investigate whether plasma GDF-15 constituted risk biomarkers for future cardiovascular events in patients with intermediate CAD. METHODS: A prospective study was performed based on 541 patients with intermediate CAD (20%-70%). GDF-15 of each patient was determined in a blinded manner. The primary endpoint was major adverse cardiac event (MACE), which was defined as a composite of all-cause death, nonfatal myocardial infarction, revascularization and readmission due to angina pectoris. RESULTS: After a median follow-up of 64 months, 504 patients (93.2%) completed the follow-up. Overall, the combined endpoint of MACE appeared in 134 patients (26.6%) in the overall population: 26 patients died, 11 patients suffered a nonfatal myocardial infarction, 51 patients underwent revascularization, and 46 patients were readmitted for angina pectoris. The plasma levels of GDF-15 (median: 1172.02 vs. 965.25 pg/mL, P = 0.014) were higher in patients with ischemic events than those without events. After adjusting for traditional risk factors, higher GDF-15 levels were significantly associated with higher incidence of the composite endpoint of MACE (HR = 1.244, 95% CI: 1.048-1.478, Quartile 4 vs. Quartile 1, P = 0.013). CONCLUSIONS: The higher level of GDF-15 was an independent predictor of long-term adverse cardiovascular events in patients with intermediate CAD.

Long-term outcomes of PCI vs. CABG for ostial/midshaft lesions in unprotected left main coronary artery.

BACKGROUND: There are limited data on long-term (> 5 years) outcomes of drug-eluting stent (DES) implantation compared with coronary artery bypass grafting (CABG) for ostial/midshaft left main coronary artery (LMCA) lesions. METHODS: Of the 259 consecutive patients in Beijing Anzhen Hospital with ostial/midshaft LMCA lesions, 149 were treated with percutaneous coronary intervention (PCI) with DES and 110 were with CABG. The endpoints of the study were death, repeat revascularization, myocardial infarction (MI), stroke, the composite of cardiac death, and major adverse cardiac and cerebrovascular events (MACCE, the composite of cardiac death, MI, stroke or repeat revascularization).The duration of follow-up is 7.1 years (interquartile range 5.3 to 8.2 years). RESULTS: There is no significant difference between the PCI and CABG group during the median follow-up of 7.1 years (interquartile range: 5.3-8.2 years) in the occurrence of death (HR: 0.727, 95% CI: 0.335-1.578; P = 0.421), the composite endpoint of cardiac death, MI or stroke (HR: 0.730, 95% CI: 0.375-1.421; P = 0.354), MACCE (HR: 1.066, 95% CI: 0.648-1.753; P = 0.801), MI (HR: 1.112, 95% CI: 0.414-2.987; P = 0.833), stroke (HR: 1.875, 95% CI: 0.528-6.659; P = 0.331), and repeat revascularization (HR: 1.590, 95% CI: 0.800-3.161; P = 0.186). These results remained after multivariable adjusting. CONCLUSION: During a follow-up up to 8.2 years, we found that DES implantation had similar endpoint outcomes compared with CABG.

Impact of mean platelet aggregation degree on long-term clinical outcomes among patients undergoing a complex percutaneous coronary intervention.

OBJECTIVE: The aim of this study was to evaluate the association between the mean platelet aggregation degree and long-term clinical outcomes in patients receiving a complex percutaneous coronary intervention (CPCI). PATIENTS AND METHODS: We screened 2141 patients after a percutaneous coronary intervention (PCI) treated with aspirin and clopidogrel. CPCI was defined as a procedure targeted to at least one of the following: left main disease, bifurcation lesion, ostial lesion, chronic total occlusion, and small-vessel stenting. ADP-induced platelet aggregation was serially measured by light transmission aggregometry at least three times after PCI and the mean value was calculated. The population was categorized on the basis of the mean ADP degree and the presence of CPCI. The primary endpoint measured was a major adverse cardiovascular and cerebral event (MACCE). RESULTS: A total of 1245 patients enrolled in the study were divided into four groups: group A (CPCI and ADP≥40%), group B (CPCI and ADP<40%), group C (non-CPCI and ADP≥40%), and group D (non-CPCI and ADP<40%). The median follow-up was 29.9 months. The Cox multivariate analysis suggested that group A was an independent risk factor for MACCE (hazard ratio: 2.70, 95% confidence interval: 1.25-5.81; P<0.001). Compared with group A, the remaining groups (groups B, C, and D) had a lower rate of MACCE. When group C was set as the reference, groups B and D had similar risks for primary endpoints. CONCLUSION: Patients undergoing CPCI with a high mean ADP degree are at a high risk for MACCE. Serial platelet function testing is therefore important in patients receiving CPCI.

SYNTAX Score-II Predicts Long-Term Mortality in Patients Who Underwent Left Main Percutaneous Coronary Intervention Treated With Second-Generation Drug-Eluting Stents.

The aim of this study was to evaluate the capacity of the SYNTAX Score-II (SS-II) to predict long-term mortality in patients undergoing left main percutaneous coronary intervention (LM-PCI) treated with second-generation drug-eluting stents (DES).Data from 487 consecutive patients with de novo left main coronary artery disease undergoing PCI were retrospectively studied. The patients were divided into tertiles according to the SS-II: low SS-II tertile (SS-II ≤ 22), intermediate SS-II tertile (SS-II of 23 to 30), and high SS-II tertile (SS-II ≥ 30). The survival curves were estimated by the Kaplan-Meier method. Univariate and multivariate Cox proportional hazard regression analyses were performed to evaluate the possible associations between the SS-II and the rates of long-term mortality. The predictive ability of the SS-II for mortality was assessed and compared with the SYNTAX score (SS) alone by an area under the receiver operator curve (AUC).The overall SS-II was 27.3 ± 9.1. At a mean follow-up of 5.1 years, the long-term mortality was 6.0%. The rates of mortality were 2.4%, 3.4%, and 11.6%, respectively (P < 0.0001) in the low, intermediate, and high SS-II tertiles. The cardiac mortality rates were 1.8%, 1.4%, and 8.1%, respectively (P = 0.002) among patients in the 3 groups. By multivariate analysis, SS-II was an independent predictor of the long-term mortality (hazard ratio: 1.56, 95% confidence interval: 1.05 to 2.32; P = 0.03). The AUC demonstrated a substantially higher predictive accuracy of the SS-II for mortality compared with the SS alone (AUC was 0.689 and 0.596, respectively).In patients with LM-PCI treated with a second-generation DES, the SS-II is an independent predictor of long-term mortality and demonstrates a superior predictability compared with the SS alone.

Impact of chronic kidney disease on patients with unprotected left main coronary artery disease treated with coronary artery bypass grafting or drug-eluting stents.

OBJECTIVES: This study aimed to evaluate clinical outcomes after percutaneous coronary intervention with drug-eluting stents (DESs) or coronary artery bypass grafting (CABG) in unprotected left main coronary artery (ULMCA) disease patients with and without chronic kidney disease. BACKGROUND: The optimal coronary revascularization strategy for ULMCA disease patients with chronic kidney disease remains uncertain. METHODS: The sample included 818 ULMCA disease patients who received DESs (n=358) or underwent CABG (n=460). We retrospectively compared clinical parameters and outcomes between different endogenous creatinine clearance rates [estimated glomerular filtration rates (eGFRs), ml/min×1.73 m]. RESULTS: The incidences of major adverse cardiocerebral events, all-cause death, cardiac death, and stroke were not significantly different between the DES and the CABG groups. The DES group had significantly higher risks of myocardial infarction (MI) and target vessel revascularization than the CABG group. Compared with the CABG group, the hazard ratios for target vessel revascularization were 3.965 [95% confidence interval (CI): 1.743-9.023, P=0.001] in the eGFR of at least 60 group and 46.463 (95% CI: 4.558-473.639, P=0.001) in the eGFR 45-59 group. The rate of MI was higher in patients treated with DESs in the eGFR of less than 45 group (hazard ratio: 14.098, 95% CI: 1.123-176.988, P=0.040). CONCLUSION: For patients with ULMCA disease at risk of higher repeat revascularization with normal renal function or eGFR of at least 45 ml/min×1.73 m, DESs are a safe alternative to CABG. However, for patients with severely reduced kidney function (eGFR<45 ml/min×1.73 m), DESs should be selected after careful evaluation of MI risk.

Very Long-term Outcomes and Predictors of Percutaneous Coronary Intervention with Drug-eluting Stents Versus Coronary Artery Bypass Grafting for Patients with Unprotected Left Main Coronary Artery Disease.

BACKGROUND: There are limited data on longer-term outcomes (>5 years) for patients with unprotected left main coronary artery (ULMCA) disease who underwent percutaneous coronary intervention (PCI) in the drug-eluting stents (DES) era. This study aimed at comparing the long-term (>5 years) outcomes of patients with ULMCA disease underwent PCI with DES and coronary artery bypass grafting (CABG) and the predictors of adverse events. METHODS: All consecutive patients with ULMCA disease treated with DES implantation versus CABG in our center, between January 2003 and July 2009, were screened for analyzing. A propensity score analysis was carried out to adjust for potential confounding between the two groups. RESULTS: Nine hundred and twenty-two patients with ULMCA disease were enrolled for the analyses (DES = 465 vs. CABG = 457). During the median follow-up of 7.1 years (interquartile range 5.3-8.2 years), no difference was found between PCI and CABG in the occurrence of death (P = 0.282) and the composite endpoint of cardiac death, myocardial infarction (MI) and stroke (P = 0.294). Rates of major adverse cardiac and cerebrovascular events were significantly higher in the PCI group (P = 0.014) in large part because of the significantly higher rate of repeat revascularization (P < 0.001). PCI was correlated with the lower occurrence of stroke (P = 0.004). Multivariate analysis showed ejection fraction (EF) (P = 0.012), creatinine (P = 0.016), and prior stroke (P = 0.031) were independent predictors of the composite endpoint of cardiac death, MI, and stroke in the DES group, while age (P = 0.026) and EF (P = 0.002) were independent predictors in the CABG group. CONCLUSIONS: During a median follow-up of 7.1 years, there was no difference in the rate of death between PCI with DES implantation and CABG in ULMCA lesions in the patient cohort. CABG group was observed to have significantly lower rates of repeat revascularization but higher stroke rates compared with PCI. EF, creatinine, and prior stroke were independent predictors of the composite endpoint of cardiac death, MI, and stroke in the DES group, while age and EF were independent predictors in the CABG group.

The Importance of the Mean Platelet Aggregation Degree in Long-term Dual Antiplatelet Therapy Following Drug-Eluting Stent Implantation.

INTRODUCTION: The dual antiplatelet therapy (DAPT) and the response of clopidogrel were two pivotal issues in drug-eluting stent (DES) era. AIMS: To analyze the combined impacts of DAPT and the response to clopidogrel to evaluate their long-term effect on patients undergoing DES implantation. METHODS: Platelet aggregation was serially measured by light transmission aggregometry in all eligible patients during the course of treatment with DAPT, and the mean platelet aggregation degree of each participant was calculated. Based on the duration of DAPT and the mean platelet aggregation degree, all the enrolled patients were then divided into four groups. The primary endpoint was a composite of major adverse cardiovascular events. RESULTS: We analyzed 1245 suitable patients in this study. They were divided into four groups: Group A (12-month DAPT & low platelet aggregation degree) with 233 subjects, Group B (12-month DAPT & high platelet aggregation degree) with 260 subjects, Group C (>12-month DAPT & low platelet aggregation degree) with 374 subjects, and Group D (>12-month DAPT & high platelet aggregation degree) with 378 subjects. Group C was associated with a decreased incidence of primary endpoints [HR 0.512, 95%CI (0.27-0.97); P = 0.040]. The Cox proportional hazard model was further analyzed with Groups A and B combined as the reference category [HR for Group C vs. Group A, 0.84, 95%CI (0.33-2.15); P = 0.719; HR for Group C vs. Group B, 0.45, 95%CI (0.21-0.98); P = 0.043]. Their respective multivariate Cox proportional hazard regressions confirmed these trends. CONCLUSIONS: The mean platelet aggregation degree is of importance in long-term use of DAPT; extension of DAPT beyond 1 year should be implemented cautiously in patients implanted with DESs.

[Long-term outcomes of patients with unprotected left main coronary artery disease post revascularization].

OBJECTIVE: To compare the long-term real-world outcomes of consecutive patients with unprotected left main coronary artery disease (ULMCA) underwent percutaneous coronary intervention (PCI) with drug-eluting stents (DES) and coronary artery bypass grafting (CABG). METHODS: Consecutive patients with ULMCA (defined as stenosis ≥ 50%) undergoing DES implantation or CABG between January 2003 to July 2009 in Beijing Anzhen Hospital were enrolled. The follow-up period extended through August 2013. The end points of the study were death, cardiac death, repeat revascularization, myocardial infarction (MI), stroke, the composite of cardiac death, MI or stroke and MACCE (major adverse cardiac and cerebrovascular events, the composite of cardiac death, MI, stroke or repeat revascularization). RESULTS: From January 2003 to July 2009, 922 ULMCA patients were enrolled in this study (465 PCI patients, and 457 CABG patients). The median follow-up was 7.1 years (interquartile range 5.3 to 8.2 years). The crude relative risk was as follows: overall death rate (13.0% (41/465) vs. 22.1% (72/457), P = 0.009), stroke rate (5.8% (11/465) vs. CABG 18.9% (46/457), P < 0.001) were significantly lower whereas the rate of repeat revascularization (32.3% (110/465) vs. CABG 19.2% (58/457), P < 0.001) was significantly higher in PCI group than in CABG group. MI rate was similar between PCI and CABG group (13.9% (33/465) vs. 6.7% (26/457), P = 0.196). MACCE rate was also similar between the 2 groups (42.9% (145/465) vs. 42.5% (142/457), P = 0.122). After multivariate adjusting, there was no significant difference in rates of death, MI and a composite of serious outcomes (cardiac death, MI, or stroke) between the 2 groups. Rates of MACCE were significantly higher in the PCI group (P = 0.009) due to increased rate of repeat revascularization (P < 0.001). However, stroke rate was still significantly higher in CABG group (P = 0.001) after multivariate adjusting. CONCLUSION: During a follow-up up to 8.2 years, the survival rate is similar between the PCI and the CABG group in patients with ULMCA disease. The rate of repeat revascularization is significantly higher and stroke rate is significantly lower in the PCI group compared to CABG group.

The Long-Term Influence of Tissue Inhibitor of Matrix Metalloproteinase-1 in Patients with Mild to Moderate Coronary Artery Lesions in a Chinese Population: A 7-Year Follow-Up Study.

OBJECTIVES: Matrix metalloproteinase-9 (MMP-9), tissue inhibitor of matrix metalloproteinase-1 (TIMP-1) and their ratio (MMP-9/TIMP-1) are involved in multiple processes that are associated with coronary heart disease and are especially associated with cardiovascular events. However, few long-term population-based clinical studies have evaluated the role of these factors in cardiovascular events in a Chinese population. METHODS: A prospective study was performed on 560 patients with mild to moderate coronary artery lesions. MMP-9, TIMP-1 and their ratio were determined. RESULTS: A total of 522 of patients completed the follow-up. The median follow-up time was 64 months. Kaplan-Meier analysis demonstrated a clear increase of the incidence of major adverse cardiac events (MACEs) during the follow-up period in subjects with above-median levels of TIMP-1 (p = 0.033), whereas there was no association with either MMP-9 (p = 0.199) or MMP-9/TIMP-1 (p = 0.631). Multivariate Cox proportional hazards analysis showed the same results after further adjustment for covariates. Patients with above-median levels of TIMP-1 were more likely to suffer from adverse outcomes than patients with below-median levels of TIMP-1. However, the lack of relationship of MACEs with MMP-9 and MMP-9/TIMP-1 remained. CONCLUSIONS: Higher circulating TIMP-1 concentrations were associated with cardiovascular events during long-term follow-up of Chinese patients with mild to moderate coronary artery lesions.

Predictive Ability of the SYNergy Between Percutaneous Coronary Intervention with TAXus and Cardiac Surgery Score II for Long-term Mortality in Patients with Three-vessel Coronary Artery Disease Undergoing Percutaneous Coronary Intervention Treated with Second-generation Drug-eluting Stents.

BACKGROUND: The SYNergy between percutaneous coronary intervention with TAXus and cardiac surgery Score II (SS-II) can well predict 4-year mortality in patients with complex coronary artery disease (CAD), and guide decision-making between coronary artery bypass graft surgery and percutaneous coronary intervention (PCI). However, there is lack of data regarding the utility of the SS-II in patients with three-vessel CAD undergoing PCI treated with second-generation drug-eluting stents (DES). The purpose of the present study was to evaluate the ability of the SS-II to predict long-term mortality in patients with three-vessel CAD undergoing PCI with second-generation DES. METHODS: Totally, 573 consecutive patients with de novo three-vessel CAD who underwent PCI with second-generation DES were retrospectively studied. According to the tertiles of the SS-II, the patients were divided into three groups: The lowest SS-II tertile (SS-II ≤20), intermediate SS-II tertile (SS-II of 21-31), and the highest SS-II tertile (SS-II ≥32). The survival curves of the different groups were estimated by the Kaplan-Meier method. Univariate and multivariate Cox proportional hazard regression analyses were performed to evaluate the relationship between the SS-II and 5-year mortality. The performance of the SS-II with respect to predicting the rate of mortality was studied by calculating the area under the receiver operator characteristic (ROC) curve. The predictive ability of the SS-II for 5-year mortality was evaluated and compared with the SS alone. RESULTS: The overall SS-II was 27.6 ± 9.0. Among patients in the lowest, intermediate and the highest SS-II tertiles, the 5-year rates of mortality were 1.6%, 3.2%, and 8.6%, respectively (P = 0.003); the cardiac mortality rates were 0.5%, 1.9%, and 5.2%, respectively (P = 0.014). By multivariable analysis, adjusting for the potential confounders, the SS-II was an independent predictor of 5-year mortality (hazard ratio: 2.45, 95% confidence interval: 1.38-4.36; P = 0.002). The SS-II demonstrated a higher predictive accuracy for 5-year mortality compared with the SS alone (the area under the ROC curve was 0.705 and 0.598, respectively). CONCLUSION: The SS-II is an independent predictor of 5-year mortality in patients with three-vessel CAD undergoing PCI treated with second-generation DES, and demonstrates a superior predictive ability over the SS alone.

[Clinical characteristics among CABG or PCI which to treat chronic kidney disease with unprotected left main coronary artery disease].

OBJECTIVE: To explore the clinical characteristics and prognosis of patients with chronic kidney disease with unprotected left main (ULM) coronary artery disease undergoing coronary artery bypass grafting (CABG) or percutaneous coronary intervention (PCI). METHODS: A total of 601 unprotected left main coronary artery disease patients were recruited. According to the values of endogenous creatinine clearance rate (Ccr), they were divided into three groups of <45 ml/min (n=40), 45-59 ml/min (n=96) and ≥60 ml/min (n=465). Retrospective comparisons were made for the clinical parameters and prognosis of ULM patients in different Ccr groups with different therapies. RESULTS: In Ccr≥60 ml/min group, the valves of left ventricular ejection fraction (LVEF) were lower in patients undergoing CABG. Patients with complete total occlusion (CTO) and complete revascularizations were much more than those undergoing PCI. In Ccr≥60 ml/min and Ccr 45-59 ml/min groups, multivessel disease was frequent in CABG-treated patients. No significant difference existed among three groups in major adverse cardiac and cerebrovascular event (MACCE), overall mortality or cardiac mortality. CONCLUSION: PCI is both safe and efficacious for chronic renal insufficiency patients with ULM.

Influence of diabetes mellitus on long-term outcomes of patients with unprotected left main coronary artery disease treated with either drug-eluting stents or coronary artery bypass grafting.

Whether the effect of diabetes on patients with unprotected left main coronary artery (ULMCA) disease differs according to different strategies of revascularization was unknown. This study was conducted to evaluate the impact of diabetes on patients with ULMCA disease treated with either percutaneous coronary intervention (PCI) or coronary-artery bypass grafting (CABG).A total of 922 patients with ULMCA disease who received drug-eluting stent (DES) (n = 465) implantation or underwent CABG (n = 457) were retrospectively analyzed. We compared the effects of these 2 treatments on clinical outcomes (death, myocardial infarction, stroke, repeat revascularization, and the composite of death, myocardial infarction, or stroke), according to diabetic status.During the median follow-up of 7.1 years (interquartile range, 5.3 to 8.2 years), no difference was found between PCI and CABG in the adjusted occurrence of death (P = 0.112) and the composite endpoints of death, myocardial infarction, and stroke (P = 0.235). Significantly higher incidence of repeat revascularization (P < 0.001) was observed in the DES group, whereas the CABG group had a significantly higher rate of stroke (P = 0.001). These trends were consistent in both diabetic and nondiabetic patients. We did not observe significant interactions between treatment outcomes and the presence or absence of diabetes after adjustment for covariates (P(interaction) = 0.580 for the composite of death, MI and stroke, P(interaction) = 0.685 for death, P(interaction) = 0.416 for MI, P(interaction) = 0.470 for stroke, and P(interaction) = 0.502 for repeat revascularization).Presence of diabetes was not important for decision-making between CABG and PCI in patients with ULMCA disease.

The relationship between revascularization extent and the long-term prognosis of patients with stable angina pectoris and three-vessel disease treated by percutaneous coronary intervention in the era of drug-eluting stents.

BACKGROUND: The effects of revascularization extent (RE) on the long-term prognosis of patients with stable angina pectoris and 3-vessel disease who underwent percutaneous coronary intervention were unknown. HYPOTHESIS: The study was aimed at evaluating whether there was an effect of RE on patients presenting with stable angina pectoris and 3-vessel disease. METHODS: RE, which was calculated by baseline SYNTAX (Synergy Between Percutaneous Coronary Intervention With Taxus and Cardiac Surgery) score minus residue SYNTAX score divided by baseline SYNTAX score, was initially used in our study. Five hundred fifty-eight patients presenting with stable angina pectoris and 3-vessel disease were assigned to and compared among tertiles according to RE and clinical outcomes. The primary end point was the major adverse cardiovascular event (MACE), a composite of cardiac death, nonfatal myocardial infarction (MI), and any repeat revascularization. RESULTS: The median follow-up period was 56.9 months (interquartile range, 52.1-63.6). The incidence of MACE increased significantly as RE increased (13.3%, 31.4%, and 44.1%, log-rank P < 0.001). The same tendency was observed in occurrences of target-vessel failure (TVF) (a composite of cardiac death, MI, or target-vessel revascularization) (8.8%, 20.3%, and 28.4%, log-rank P < 0.001), repeat revascularization (11.8%, 26.2%, and 35.6%, log-rank P < 0.001), and MI (1.1%, 2.9%, and 12.6%, log-rank P < 0.001). Multivariate analysis confirmed the tendencies mentioned above. CONCLUSIONS: For patients presenting with stable angina pectoris and 3-vessel disease, the increasing extent of revascularization resulted in a less favorable prognosis.

Duration of dual antiplatelet therapy after implantation of the first-generation and second-generation drug-eluting stents.

OBJECTIVE: This study was carried out to determine the effect of the use of dual antiplatelet therapy (DAPT) for more than 12 months on long-term clinical outcomes in patients who had undergone a percutaneous coronary intervention with the first and second generations of drug-eluting stents (DES). BACKGROUND: The potential benefits of the use of DAPT beyond a 12-month period in patients receiving DES have not been established clearly. Moreover, it is also unclear whether the optimal duration of DAPT is similar for all DES types. METHODS: A total of 2141 patients with coronary artery disease treated exclusively with Cypher sirolimus-eluting stents (SES) or Endeavor zotarolimus-eluting stents (ZES) were considered for retrospective analysis. The primary endpoint [a composite of all-cause mortality, nonfatal myocardial infarction (MI), and stroke] was compared between the 12-month DAPT and the >12-month DAPT group. RESULTS: A total of 1870 event-free patients on DAPT at 12 months were identified. The average follow-up was 28.2±7.4 months. The primary outcomes were similar between the two groups (4.1% 12-month DAPT vs. 1.9% >12-month DAPT; P=0.090). Incidences of death, MI, stroke, and target vessel revascularization did not differ significantly between the two groups. Subgroup analysis showed that in the patients with hypertension, >12-month DAPT significantly reduced the occurrence of death/MI/stroke compared with that in the 12-month DAPT group (P=0.04). In patients implanted with SES, the primary outcome was significantly lower with the >12-month DAPT group (5.2% 12-month DAPT vs. 1.6% >12-month DAPT; P=0.016), whereas in patients with ZES, the primary outcome was comparable between the two groups (2.3% 12-month DAPT vs. 2.0% >12-month DAPT; P=0.99). CONCLUSION: In our study, for all patients, >12-month DAPT in patients who had received DES was not significantly more effective than 12-month DAPT in reducing the rate of death/MI/stroke. Our findings, that patients who received SES benefit from >12-month DAPT whereas extended use of DAPT was not significantly more effective in those implanted with ZES, implied that the optimal duration of DAPT was different depending on different types of DES.