scholarly journals Cardiovascular Screening for the Asymptomatic Patient with Diabetes: More Cons Than Pros

2017 ◽  
Vol 2017 ◽  
pp. 1-19 ◽  
Author(s):  
Konstantinos Makrilakis ◽  
Stavros Liatis
Keyword(s):  
Medical Therapy ◽  
Coronary Atherosclerosis ◽  
Randomized Clinical Trials ◽  
Artery Bypass ◽  
Coronary Intervention ◽  
Morbidity And Mortality ◽  
Cvd Risk ◽  
Increased Risk ◽  
Percutaneous Coronary ◽  
Revascularization Procedures

Diabetes mellitus is associated with an increased risk of coronary heart disease (CHD) morbidity and mortality. Although it frequently coexists with other cardiovascular disease (CVD) risk factors, it confers an increased risk for CVD events on its own. Coronary atherosclerosis is generally more aggressive and widespread in people with diabetes (PWD) and is frequently asymptomatic. Screening for silent myocardial ischaemia can be applied in a wide variety of ways. In nearly all asymptomatic PWD, however, the results of screening will generally not change medical therapy, since aggressive preventive measures, such as control of blood pressure and lipids, would have been already indicated, and above all, invasive revascularization procedures (either with percutaneous coronary intervention or coronary artery bypass grafting) have not been shown in randomized clinical trials to confer any benefit on morbidity and mortality. Still, unresolved issues remain regarding the extent of the underlying ischaemia that might affect the risk and the benefit of revascularization (on top of optimal medical therapy) in ameliorating this risk in patients with moderate to severe ischaemia. The issues related to the detection of coronary atherosclerosis and ischaemia, as well as the studies related to management of CHD in asymptomatic PWD, will be reviewed here.

Abstract 17283: De-Escalation of Antiplatelet Therapy in Patients With Coronary Artery Disease Undergoing Percutaneous Coronary Intervention: A Meta-Analysis of Randomized Clinical Trials

Circulation ◽  
2018 ◽  
Vol 138 (Suppl_1) ◽  
Author(s):  
Babikir Kheiri ◽  
Mohammed Osman ◽  
Ahmed Abdalla ◽  
Sahar Ahmed ◽  
Khansa Osman ◽  
...  
Keyword(s):  
Clinical Trials ◽  
Percutaneous Coronary Intervention ◽  
Randomized Clinical Trials ◽  
Maintenance Phase ◽  
Coronary Intervention ◽  
Major Adverse Cardiovascular Events ◽  
Safety And Efficacy ◽  
Coronary Syndrome ◽  
Increased Risk ◽  
Percutaneous Coronary

Introduction: Potent P2Y 12 -receptor inhibitors are recommended in the management of acute coronary syndrome (ACS) treated with percutaneous coronary intervention (PCI). As the risk of thrombotic complications from an ACS event is highest in the early “ischemic phase,” the greatest benefit of potent P2Y 12 blockade occurs early. However, the risk of bleeding from such therapy tends to occur with chronic treatment during the “maintenance phase.” Therefore, a stage-adapted strategy with the early use of potent P2Y 12 blockade in acute treatment, followed by de-escalation to clopidogrel during the maintenance phase is common. Nevertheless, clinical outcomes supporting this strategy are lacking. Hypothesis: This study aimed to evaluate the safety and efficacy of antiplatelet de-escalation compared with continuation in patients with ACS treated with PCI. Methods: Electronic databases search were conducted for all randomized clinical trials (RCTs) that evaluated the safety and efficacy of antiplatelet de-escalation compared with continuation in patients with ACS treated with PCI. A random-effects model was used to calculate the pooled summary estimates. Results: We included 3 RCTs with 3,391 total patients (median follow-up 12 months). The net clinical outcome (composite of thrombotic or bleeding events) was significantly reduced in the switched group compared with the continued group (8.7% vs 12.1%; risk ratio (RR): 0.64; 95% confidence interval (CI): 0.43-0.97; P=0.03). However, there were no significant differences between groups in major adverse cardiovascular events (RR: 0.78; 95% CI: 0.55-1.11; P=0.17), all BARC (Bleeding Academic Research Consortium) types bleeding (RR: 0.61; 95% CI: 0.33-1.11; P=0.10), or BARC types ≥2 bleeding (RR: 0.49; 95% CI: 0.19-1.26; P=0.14). Conclusions: Our results suggest a net clinical benefit of de-escalation therapy shortly after PCI in ACS patients, without increased risk of MACE or bleeding, though further adequately powered trials are needed to confirm this finding.

scholarly journals Dual Antiplatelet Therapy after PCI: When Could We Go Shorter?

2021 ◽  
Author(s):  
Marcel Santaló-Corcoy ◽  
Guillaume Marquis-Gravel ◽  
Jean-François Tanguay
Keyword(s):  
Antiplatelet Therapy ◽  
Randomized Clinical Trials ◽  
Dual Antiplatelet Therapy ◽  
Interventional Cardiology ◽  
Bleeding Risk ◽  
Coronary Intervention ◽  
Increased Risk ◽  
Percutaneous Coronary ◽  
High Bleeding Risk

The optimal duration of dual antiplatelet therapy (DAPT) after percutaneous coronary intervention (PCI) remains an important clinical question in interventional cardiology. Several clinical and angiographic variables are associated with an increased risk for thrombotic events, and prolonged DAPT duration may improve long term clinical outcome. However, some patients also present high bleeding risk (HBR) characteristics and may require a shorter DAPT duration. The guidelines recommendations consider the data from randomized clinical trials, however numerous exclusion criteria may create gaps in the evidence leading to uncertainties, the need for expert opinion and patient level decision making. Furthermore, the stent platforms have evolved in such way that opportunities now exist to shorten duration of DAPT. This chapter will review the variables associated with ischemic and bleeding risks as well as different stent platforms to help clinicians optimize DAPT duration in patients undergoing PCI.

Abstract 14143: Percutaneous Coronary Intervention in Very Elderly Patients With Prior Coronary Artery Bypass Grafts Presenting With Acute Myocardial Infarction

Circulation ◽  
2020 ◽  
Vol 142 (Suppl_3) ◽  
Author(s):  
Derek Q Phan ◽  
Ara ROSTOMIAN ◽  
Mingsum Lee ◽  
naing a moore ◽  
prakash mansukhani ◽  
...  
Keyword(s):  
Myocardial Infarction ◽  
Elderly Patients ◽  
Medical Therapy ◽  
Artery Bypass ◽  
Coronary Intervention ◽  
Coronary Artery Bypass Grafts ◽  
Bypass Grafts ◽  
Very Elderly ◽  
Percutaneous Coronary ◽  
All Cause Mortality

Introduction: There is limited data on the benefits of percutaneous coronary intervention (PCI) in very elderly patients with prior coronary artery bypass grafts (CABG). Therefore, we sought to evaluate the outcomes of PCI versus medical therapy alone in very elderly patients with prior CABG who present with acute myocardial infarction (AMI). Methods: Retrospective study of patients ≥ 80 years old with prior CABG who underwent invasive coronary angiography for AMI at Kaiser Permanente Los Angeles Medical Center between June 2009 and February 2019. Patients were treated with PCI or medical therapy alone. Inverse Probability Treatment of Weighting (IPTW) was used to balance baseline characteristics between treatment groups and cox proportional hazard regression analysis was utilized. Outcomes evaluated were all-cause mortality and non-fatal MI. Results: There were 347 patients (average age 83.6±3.2 years, 18% female) analyzed. Of these 167 (48%) underwent PCI. Compared to medical therapy alone, the PCI group was more likely to have left main disease (15% vs 2.8%, p<0.01) and higher ejection fraction (48.0± vs 44.4± %, p=0.02); but less likely to have history of atrial fibrillation (31.7% vs 45.6%, p<0.01). To adjust for significant differences between groups, IPTW was utilized to balance covariates (all p>0.05). At a median follow-up of 27.6 months (interquartile range 9.7-52 months), there were no significant differences in all-cause mortality (Hazard Ratio [HR] 0.93, 95% Confidence Interval [CI] 0.88-1.32, p=0.5), and non-fatal MI (HR 0.95, 95% CI 0.72-1.26, p=0.7). Conclusion: PCI did not improve clinical outcomes over medical therapy alone in very elderly patients ≥ 80 years of age with prior CABG presenting with AMI. Further studies are needed to delineate the role of PCI in this high-risk unique population.

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