scholarly journals The ISCHEMIA trial: optimal medical therapy against PTCA in the stable patient: the endless story

2021 ◽  
Vol 23 (Supplement_E) ◽  
pp. E55-E58
Author(s):  
Andrea Santucci ◽  
Claudio Cavallini
Keyword(s):  
Coronary Angiography ◽  
Medical Therapy ◽  
Coronary Revascularization ◽  
Stable Coronary Artery Disease ◽  
Prognostic Impact ◽  
Axial Tomography ◽  
Aggressive Approach ◽  
Invasive Approach ◽  
Coronary Syndrome ◽  
Non Invasive

Abstract In patients with acute coronary syndrome, an aggressive approach with coronary angiography and revascularization leads to important benefits compared to medical therapy alone. On the contrary, the prognostic impact of coronary revascularization in patients suffering from stable coronary artery disease has long been the subject of debate. The pivotal study in this area is COURAGE, published in 2007, in which coronary revascularization showed no benefit about the combined endpoint of death from all causes and acute myocardial infarction (AMI), compared to medical therapy. The ISCHEMIA study, published in 2020, compared selective coronary angiography and revascularization vs. a non-invasive approach. By protocol, the patients were initially evaluated with coronary computed axial tomography angiography: in case of coronary stenosis >50%, they were then randomized to the two strategies. While in the invasive arm patients were revascularized, in the non-invasive arm revascularization was used only in case of patient destabilization. As in COURAGE, the results of ISCHEMIA did not demonstrate superiority of revascularization over medical therapy alone for a combined endpoint of cardiovascular death, AMI, or hospitalization for unstable angina, heart failure, or cardiac arrest. Based on recent evidence from ISCHEMIA, it is therefore confirmed that coronary revascularization in stable patients does not seem to improve the prognosis compared to medical therapy alone.

Diagnostic accuracy of Instantaneous Wave-Free Ratio (iFR) for the assessment of myocardial ischaemia: a comparison with non-invasive stress imaging

2020 ◽  
Vol 41 (Supplement_2) ◽  
Author(s):  
L Stazzoni ◽  
L Tessandori ◽  
P Spontoni ◽  
M Angelillis ◽  
C Giannini ◽  
...  
Keyword(s):  
Diagnostic Accuracy ◽  
Myocardial Ischaemia ◽  
Gold Standard ◽  
Coronary Revascularization ◽  
Stress Test ◽  
Invasive Coronary Angiography ◽  
Coronary Syndrome ◽  
Non Invasive ◽  
Coronary Stenoses ◽  
Epicardial Stenosis

Abstract Background Instantaneous Wave-Free Ratio (iFR) allows for the assessment of the haemodynamic effects of epicardial coronary stenoses without the need for hyperaemia; iFR is currently recommended as a means to evaluate myocardial ischaemia. Purpose To assess the diagnostic accuracy of iFR with respect to the identification of coronary epicardial stenoses causing ischemia. Therefore, we combined anatomical (% stenosis at invasive coronary angiography, ICA) and functional (non-invasive imaging stress test, NIST) information to obtain a “gold standard” for the identification of stenoses causing ischaemia. Methods We enrolled 71 patients (52 male, 19 female; age mean 68.4±8.1 years) with chronic coronary syndrome or low-risk acute coronary syndrome without ST segment elevation who had at least a NIST and who had at least one vessel with a 50%-85% stenosis at ICA. iFR was measured in all coronary arteries with stenosis >50% and categorised according to the 0.89 threshold for ischaemia. Results iFR was assessed in 122 vessels. In a per-vessel analysis, in 56.7% ischaemia was present both at iFR and NIST, in 21.3% ischaemia was absent in both, while in 23.0% ischaemia was found at NIST but not confirmed by iFR. The overall accuracy of iFR with respect to NIST was 90.1%. However, when considering as the “gold standard” for coronary disease causing ischaemia the contemporary presence of an epicardial stenosis >70% at ICA and a positive NIST, the diagnostic accuracy of iFR greatly improved. The sensibility, specificity, PPV, NPV and accuracy were 96.5%, 75.0%, 73.3%, 96.7% and 84.4%, respectively. In case of discordance between NIST and iFR, revascularization was based on iFR. At a mean follow-up of 23±18 months, the composite endpoint of MACE (major adverse cardiac events, defined as the composite of all-cause death, nonfatal MI and unplanned coronary revascularization) occurred in 16.4%, while death/MI occurred in 11.9%. Stratification according to the per-patient concordance between iFR and NIST showed no significant differences in rates of MACE (p=0.50) and death/MI (p=0.20). Stratification based on iFR showed a higher death/MI rate in iFR-positive patients (11.9% vs. 0%, p=0.047) and a trend to higher MACE rate (11.9% vs. 4.47% p=0.14), Conclusions The diagnostic accuracy of iFR is low when compared with NIST as the reference for myocardial ischaemia, but it is very high when compared with the combined presence of epicardial stenosis and positive NIST. Therefore, iFR can accurately guide the decision to treat or defer revascularization of intermediate coronary stenoses, being most useful in patients with multivessel CAD and when non-invasive functional data are lacking or discordant with anatomy. Funding Acknowledgement Type of funding source: None

scholarly journals Is the problem of intact coronary arteries still or is it close to solving?

2021 ◽  
Vol 26 (2) ◽  
pp. 4139
Author(s):  
A. N. Sumin
Keyword(s):  
Coronary Angiography ◽  
Coronary Arteries ◽  
Diagnostic Procedure ◽  
Invasive Coronary Angiography ◽  
Stable Coronary Artery Disease ◽  
Myocardial Revascularization ◽  
Coronary Syndrome ◽  
European Guidelines ◽  
Artery Disease ◽  
Dominant Paradigm

The dominant paradigm in the diagnosis of patients with stable coronary artery disease was the identification of patients with obstructive lesions of the coronary arteries, and then - ensuring the possibility of myocardial revascularization. The diagnostic algorithms used until recently led to the fact that in invasive coronary angiography obstructive changes in the coronary arteries were detected in less than half of the cases. In the 2019 European Guidelines for the Diagnosis of Chronic Coronary Syndrome, this algorithm was significantly revised, but the results of its implementation have not yet been published. Currently, several pathophysiological variants of angina pectoris have been proposed, which can be identified by an interventional diagnostic procedure for invasive coronary angiography. Recent studies have shown that up to 90% of patients without obstructive lesions of the epicardial coronary arteries have microvascular or vasospastic angina. This review focuses on these topical aspects of the problem of intact coronary arteries.

scholarly journals Cohort profile: the ESC-EORP Chronic Ischaemic Cardiovascular Disease Long Term (CICD LT) registry

2019 ◽  
Author(s):  
Michel Komajda ◽  
Francesco Cosentino ◽  
Roberto Ferrari ◽  
Cécile Laroche ◽  
Aldo Maggioni ◽  
...  
Keyword(s):  
Cardiovascular Disease ◽  
Coronary Revascularization ◽  
Stable Coronary Artery Disease ◽  
Research Programme ◽  
Clinical Profile ◽  
Treatment Modalities ◽  
Common Disease ◽  
Coronary Syndrome ◽  
European Society Of Cardiology

Abstract Aims The European Society of Cardiology (ESC) EURObservational Research Programme (EORP) Chronic Ischaemic Cardiovascular Disease Long Term (CICD LT) registry aims to study the clinical profile, treatment modalities, and outcomes of patients diagnosed with CICD in a contemporary environment in order to assess whether these patients at high cardiovascular (CV) risk are treated according to ESC guidelines on prevention or on stable coronary disease and to determine mid- and long-term outcomes and their determinants in this population. Methods and results Nine thousand one hundred and seventy-four patients over 18 years with documented CICD defined by a history acute coronary syndrome with/without ST elevation, previous coronary revascularization, or stable coronary artery disease were enrolled between 1 May 2015 and 31 July 2018. Individual patient data on clinical profile, biology, and treatment modalities were collected across 154 centres from 20 ESC countries. Two years of follow-up is scheduled in order to determine the following clinical outcomes: all-cause and CV death, all-cause and CV hospitalizations, changes in medications, and quality of life using the EuroQol5D-5L score. Conclusion The CICD LT is an international registry of care and outcomes of patients hospitalized with CICD which will provide insights into the contemporary profile and management of patients with this common disease.

scholarly journals Overlap of coronary disease and pulmonary arterial hypertension in systemic sclerosis

2009 ◽  
Vol 69 (01) ◽  
pp. 202-205 ◽  
Author(s):  
A Komócsi ◽  
T Pintér ◽  
R Faludi ◽  
B Magyari ◽  
J Bozó ◽  
...  
Keyword(s):  
Systemic Sclerosis ◽  
Coronary Artery ◽  
Pulmonary Arterial Hypertension ◽  
Coronary Angiography ◽  
Arterial Hypertension ◽  
Coronary Disease ◽  
Invasive Approach ◽  
Non Invasive ◽  
Flow Reserve ◽  
Pulmonary Arterial

Objectives:Pulmonary arterial hypertension (PAH) is a common complication of systemic sclerosis (SSc). Symptoms of coronary artery disease (CAD) and PAH are closely related and cardiac catheterisation is needed to confirm their diagnosis. The aim of the present work was to investigate of the extent of overlap between CAD and PAH in patients with SSc.Methods:Based on non-invasive investigations, 20 patients out of 120 were suspected to have PAH (“suspected PAH” group). Another 10 patients showed signs of coronary disease (“suspected CAD” Group). In these 30 patients, right heart catheterisation and coronary angiography were performed, and the coronary flow reserve (CFR) was assessed by thermodilution technique.Results:In the “suspected PAH” and the “suspected CAD” groups, PAH was found in 12/20 and 2/10 cases, and coronary artery stenosis in 9/20 and 6/10 cases, respectively. Severely reduced CFR was revealed in 7/20 and 3/10 cases, respectively.Conclusions:PAH, CAD and reduced CFR all show a considerable overlap in symptomatic patients with SSc. The current non-invasive investigations are neither sensitive nor specific enough to make an appropriate distinction between these different disease manifestations. A more invasive approach, such as coronary angiography at the initial catheterisation, is required to properly characterise and treat the different forms of cardiac involvement in SSc.

Trends of coronary revascularization procedures in Gaza

2019 ◽  
pp. 1-4
Keyword(s):  
Coronary Angiography ◽  
Coronary Revascularization ◽  
Artery Bypass ◽  
Myocardial Revascularization ◽  
Coronary Intervention ◽  
Coronary Syndrome ◽  
Vessel Disease ◽  
St Elevation ◽  
Revascularization Procedures ◽  
Diagnostic Coronary Angiography

Background: we investigated the results of diagnostic coronary angiography and trends in rates of myocardial revascularization procedure included Percutaneous Coronary Intervention (PCI) and Coronary Artery Bypass Grafting (CABG) procedures in Gaza between 2015 and 2018. Methods: A descriptive retrospective study based on the analysis of all diagnostic Coronary Angiographies (CAG) based on the Ministry of Health hospitals in Gaza City Report and the Center of Bureau of Statistics, to evaluate the annual rate of PCI and CABG volume have been done since January 2015until January 2019. Results: A total of 4887 diagnostic coronary angiography procedures were performed. The mean age of patients was 58.0±10.2 years. A 3245 of cases were male (66.4%). A total of 5225 revascularization procedures (PCI: 4286,CABG: 939) were performed during the study period. From 2014 to 2018 the PCI volume increased by 94 % (80/100 000 to 155/100 000)(P < 0.0001), CABG volume decreased by 47 % (30/100 000 to 17 /100 000) (P <0.0001), PCI/CABG ratio increased from 2.7 to 9.1(P<0.0001).The indications for diagnostic coronary angiography were stable angina (57% of cases), non-ST-elevation acute coronary syndrome (NSE-ACS) in 24.0%, ST-elevation myocardial infarction (STEMI) in 19.0%, the diagnostic coronary angiography results showed significant lesions in 64.5% of patients. About 19.2% of total cases have three vessel disease, 21% have two vessel disease and 24.4% of them have one vessel disease. The segments most involved were Left Anterior Descending Artery (LAD) which was involved in 47.2% of cases. Discussion: We observed dramatic increases in the total coronary revascularization procedures with a marked decrease in CABG and increase in PCI procedures in Gaza.

scholarly journals Coronary Revascularization in Patients With Stable Coronary Artery Disease: The Role of Imaging

2021 ◽  
Vol 8 ◽  
Author(s):  
Danilo Neglia ◽  
Natallia Maroz-Vadalazhskaya ◽  
Nazario Carrabba ◽  
Riccardo Liga
Keyword(s):  
Coronary Artery Disease ◽  
Coronary Artery ◽  
Coronary Revascularization ◽  
Invasive Coronary Angiography ◽  
Stable Coronary Artery Disease ◽  
Real Life ◽  
Non Invasive ◽  
Artery Disease ◽  
The Impact

In the last decades, the effective management of some cardiovascular risk factors in the general population has led to a progressive decrease in the prevalence of coronary artery disease (CAD). Nevertheless, coronary heart disease remains the major cause of death in developed and developing countries and chronic coronary syndromes (CCS) are still a major target of utilization of non-invasive cardiac imaging and invasive procedures. Current guidelines recommend the use of non-invasive imaging in patients with CCS to identify subjects at higher risk to be referred for invasive coronary angiography and possible revascularization. These recommendations are challenged by two opposite lines of evidence. Recent trials have somewhat questioned the efficacy of coronary revascularization as compared with optimal medical therapy in CCS. As a consequence the role of imaging in these patients and in in patients with ischemic cardiomyopathy is under debate. On the other hand, real-life data indicate that a consistent proportion of patients undergo invasive procedure and are revascularized without any previous non-invasive imaging characterization. On top of this, the impact of COVID-19 pandemic on the sanitary systems caused a change in the current management of patients with CAD. In the present review we will discuss these conflicting data analyzing the evidence which has been recently accumulated as well as the gaps of knowledge which should still be filled.

scholarly journals Cardiac Care of Non-COVID-19 Patients During the SARS-CoV-2 Pandemic: The Pivotal Role of CCTA

2021 ◽  
Vol 8 ◽  
Author(s):  
Edoardo Conte ◽  
Saima Mushtaq ◽  
Maria Elisabetta Mancini ◽  
Andrea Annoni ◽  
Alberto Formenti ◽  
...  
Keyword(s):  
Myocardial Infarction ◽  
Medical Therapy ◽  
Coronary Revascularization ◽  
Invasive Coronary Angiography ◽  
Diagnostic Technique ◽  
Suspected Coronary Artery Disease ◽  
St Elevation Myocardial Infarction ◽  
Clinical Indication ◽  
Non Invasive ◽  
St Elevation

Aim: The aim of this study is to evaluate the potential use of coronary CT angiography (CCTA) as the sole available non-invasive diagnostic technique for suspected coronary artery disease (CAD) during the coronavirus disease 2019 (COVID-19) pandemic causing limited access to the hospital facilities.Methods and Results: A consecutive cohort of patients with suspected stable CAD and clinical indication to non-invasive test was enrolled in a hub hospital in Milan, Italy, from March 9 to April 30, 2020. Outcome measures were obtained as follows: cardiac death, ST-elevation myocardial infarction (STEMI), non-ST-elevation myocardial infarction (NSTEMI), and unstable angina. All the changes in medical therapy following the result of CCTA were annotated. A total of 58 patients with a mean age of 64 ± 11 years (36 men and 22 women) were enrolled. CCTA showed no CAD in 14 patients (24.1%), non-obstructive CAD in 30 (51.7%) patients, and obstructive CAD in 14 (24.1%) patients. Invasive coronary angiography (ICA) was considered deferrable in 48 (82.8%) patients. No clinical events were recorded after a mean follow-up of 376.4 ± 32.1 days. Changes in the medical therapy were significantly more prevalent in patients with vs. those without CAD at CCTA.Conclusion: The results of the study confirm the capability of CCTA to safely defer ICA in the majority of symptomatic patients and to correctly identify those with critical coronary stenoses necessitating coronary revascularization. This characteristic could be really helpful especially when the hospital resources are limited

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