Management of concomitant coronary artery disease and aortic valve stenosis in the era of transcatheter aortic valve treatment

Severe calcific aortic stenosis (AS) and coronary artery disease (CAD) have common risk factors and are frequently encountered in the same patient in clinical practice. CAD has been reported in ≥ 50% of AS patients undergoing both surgical treatment and transcatheter aortic valve implantation (TAVI). In the last two decades, TAVI has been established as a less invasive alternative to surgery. Recently, more and more young and low surgical risk patients undergo TAVI. Despite the high prevalence of CAD in patients treated with TAVI, the management strategy of concomitant CAD in these patients remains an area of considerable uncertainty. This review provides an updated overview of the current knowledge about this topic and offers points for reflection about the best approach to use.

Periprocedural complications and risk factors after carotid stenting in patients with concomitant coronary artery disease

Backgrounds and purpose: To analyse the periprocedural CAS complications in patients with concomitant coronary disease. Material and methods: A prospective study analysed the frequency and characteristics of periprocedural complications after CAS in 329 patients, of whom 62.2% had symptomatic carotid stenosis > 50% and 37.8% had asymptomatic > 70%. The mean age was 70.2 (45-88) years, male/female ratio – 253/76. The degree of carotid stenosis was assessed angiographically according to NASCET criteria and was stratified by a newly proposed carotid score in three risk groups. Distal embolic protection was used in all patients. Results: Periprocedural complications were observed in 25/349 CAS interventions: TIA – 4.9%, major stroke – 0.6%, minor stroke – 1.4%, hyperperfusion syndrome – 0.3%. No MI and death were registered. Out of more than 20 factors analysed, previous MI (χ2 = 7,707; p = 0.021) and stroke (χ2 = 9,835, p = 0.043), “slow flow” (χ2 = 3.752; p = 0.001), residual stenosis> 20% (χ2 = 13.752; p = 0.001), radiation time (F = 13.323; p = 0.000), the amount of contrast used (F = 5.297; p = 0.006), contrast- induced OBN (χ2 = 25.845; p = 0.000), females with CKD (χ2 = 8.681; p = 0.013) or with a high carotid score (χ2 = 7.329; p = 0.026) were found to be predictors of complications. Conclusion: CAS is a safe procedure with low risk of MI and death in patients with concomitant coronary disease.

Influence of polyvascular disease on clinical outcome in patients undergoing transcatheter aortic valve implantation via transfemoral access

Background The influence of polyvascular disease (PVD) on the short- and long-term clinical outcomes of patients undergoing transcatheter aortic valve implantation via trans-femoral access (TF-TAVI) has not been fully elucidated. Methods A total of 2167 patients from the Optimized CathEter vAlvular iNtervention-TAVI (OCEAN-TAVI) registry who underwent TF-TAVI was studied. PVD was defined as the presence of at least two of the following vascular bed (VB) diseases: concomitant coronary artery disease (CAD), cerebrovascular disease (CVD), and peripheral artery disease (PAD). Results Patients with PVD (288 patients, 13.3%) had a higher incidence of in-hospital complications, such as AKI (16.3% vs. 7.0%, p<0.01) and disabling stroke (3.5% vs. 1.2%, p<0.01) than patients without PVD. These complications caused higher rates of procedural mortality (4.5% vs. 2.0%, p<0.01). PVD increased the risk of the 2-year rate of cardiovascular death (adjusted hazard ratio [HR], 1.61; 95% confidence interval [CI], 1.04–2.50; p<0.05); however, non-cardiovascular death, myocardial infarction, or ischemic stroke was not associated with PVD. Worsening heart failure (4.6% vs. 1.1%, p<0.01) was the main cause of cardiovascular death among patients with PVD. In a sub-analysis, compared with patients with AS alone, those with 2 VB diseases (CAD+PAD; adjusted HR, 1.93; 95% CI, 1.06–3.53; p<0.05) and 3 VB diseases (CAD+CVD+PAD; adjusted HR, 2.61; 95% CI, 1.21–5.62; p<0.05) had a higher risk of 2-year cardiovascular death. Conclusions The increased prevalence of concomitant atherosclerotic VB diseases before TF-TAVI may increase the rates of in-hospital complications and 2-year cardiovascular death. Given the higher rate of mortality in patients with PVD undergoing TF-TAVI, future studies focusing on medical therapy are needed to reduce long-term cardiovascular events in this high-risk subset.

TREATMENT OF VENOUS INSUFFICIENCY EMERGING AFTER COVID-19 DISEASE

COVID-19 disease caused by the virus called severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) is a highly contagious disease leading to hyperinflammation. Lockdown measures implemented due to COVID-19 can lead to weakness in the calf muscles of the elderly individuals who stay at home for a long time and in those receiving COVID-19 treatment in intensive care unit. Thus, venous insufficiency may develop in these circumstances. It is important to treat these patients without delay, as it may prevent the progression to chronic venous insufficiency. Our study includes eight patients who were diagnosed with COVID-19 and were discharged after being treated in various centers, but later developed venous insufficiency. Two of the patients were women and six were men. Their ages ranged from 43 to 70, and the mean age was 56.87 ± 9.70 years. The main complaints of the patients were pain, swelling, itching, tingling, burning, edema, cramping, feeling of heaviness and discoloration in the legs. All patients were hypertensive and five patients were using tobacco products. In addition, two patients had diabetes and one patient had concomitant coronary artery disease. All patients had weak calf muscles and high D-dimer levels. Venous insufficiency was diagnosed because reflux was detected in the deep veins of both lower extremities in the color venous Doppler ultrasonographic examination of the patients. Considering that venous insufficiency may be seen after recovery in COVID-19 patients, intermittent control of these patients should be done after discharge. It is important to closely monitor patients who develop venous insufficiency after COVID-19 treatment, and to strengthen the weakened calf muscles with exercises in addition to medical treatment with venoactive drugs. Since venous insufficiency may regress as a result of the strengthening of calf muscles, it should not be rushed for invasive procedures.

Characteristics and antithrombotic treatment patterns of patients with concomitant coronary artery disease and atrial fibrillation from Thailand’s COOL-AF registry

Background Concomitant coronary artery disease (CAD) and atrial fibrillation (AF) are common in clinical practice. The aim of this study was to investigate the characteristics and antithrombotic treatment patterns of patients with concomitant CAD and AF from the COhort of antithrombotic use and Optimal INR Level in patients with non-valvular atrial fibrillation in Thailand (COOL-AF Thailand) registry. Methods Registry enrollment criteria included patients aged ≥ 18 years who were diagnosed with AF for any duration at any of 27 public hospitals located across Thailand during 2014–2017. The That Clinical Trials Registry study registration number is TCTR20160113002. Statistical comparisons of characteristics and treatment strategies were performed between patients with and without CAD. Results Of a total of 3461 AF patients, 557 had concomitant CAD (16.1%). Patients with concomitant CAD and AF were significantly older, more likely to be male, had more comorbidities, and had more cardiovascular implantable electronic devices. History of stroke/transient ischemic attack and prior bleeding was not significantly different between groups. CHA2DS2-VASc score and HAS-BLED score were both higher in patients with CAD than in patients without CAD (4.17 vs. 2.78, p < 0.001, and 2.01 vs. 1.45, p < 0.001, respectively). Utilization of oral anticoagulant was less in patients with CAD (76.0% vs. 84.3%, p < 0.001). Concomitant use of antiplatelet was found to be a major cause of oral anticoagulant (OAC) underutilization. Specifically, the rate of OAC prescription was 95.9% in patients without antiplatelet, and 43.7% in patients with antiplatelet. Among patients with CAD who were on OAC, the rate of concomitant antiplatelet prescription was still high. In this group, 63% of patients were on triple therapy when percutaneous coronary intervention (PCI) with drug eluting stent was performed within 1 year, and 32.2% of patients without prior PCI or acute coronary syndrome were taking at least one antiplatelet with OAC. Conclusion Among patients with concomitant CAD and AF, physicians were reluctant to discontinue antiplatelet. The use of antiplatelet discourages physicians from prescribing OAC. Underutilization of OAC may increase the risk of ischemic stroke, and an inappropriate combination of OAC and antiplatelet may increase the risk of bleeding. Trial registration The trial has been registered with the Thai Clinical Trials Registry (TCTR) which complied with WHO International Clinical Trials Registry Platform dataset. The Registration Number is TCTR20160113002 (05/01/2016).

USE OF HERBAL IMMUNOTROPIC MEDICINES FOR COMPLEX TREATMENT OF GENERALIZED PERIODONTITIS IN PATIENTS WITH CONCOMITANT CORONARY ARTERY DISEASE

The aim: Of this study was to improve the efficiency of complex medicamental treatment of generalized periodontitis (GP) in patients with concomitant CAD using of differentiated immunotropic therapy, especially herbal medicine «Immuno-ton». Material and methods: 130 patients with GP were observed (43 without and 81 with chronic CAD – stable angina, functional classes II-III (CCS)) with detection of oral hygiene indices for Green-Vermillion, inflammation of gums PMA, bleeding of gums PBI, depth of periodontal pockets (determined by direct method). The levels of TNF-α and sPECAM-1 in gingival fluid were detected by ELISA method. Results: The following article is dedicated to studying on the effectiveness of the proposed method of GP I and II degree of development treatment in patients with a concomitant coronary artery disease (CAD) using of herbal medicines with immunomodulating effect. The offered methods provide disappearance of clinical signs of inflammation in the periodontal tissues and prevention of inflammation recurrence in the long terms. Also, it was proved that usage of the forward method of the GP immunotropic therapy with including of herbal immunomodulators leads to normalization of dynamics of tumor necrosis factor –alfa (TNF-α) and soluble platelet-endothelial cell adhesion molecule -1 (sPECAM-1) in oral fluid of abovementioned contingent of patients. Conclusions: The progression of generalized periodontitis in patients with stable coronary heart disease is accompanied with manifestation of systemic inflammation, which have been reduced by immunomodulator Immuno-Ton and extratemporal gel with “Enterosgel” and herbal concentrate “Dzherelo”.

Remote monitoring for the early detection of changes in patient status using the Home Monitoring technology

Aims: To perform the analysis of adverse events (AE) rate and trends of physiologically meaningful parameters in patients with cardiac implantable electronic devices (CIEDs) with the mobile remote monitoring option.Methods: In 9 clinical centers of the Russian Federation and 2 clinical centers of the Republic of Kazakhstan, 126 patients with an implantable cardioverter-defibrillator (ICD) or a pacemaker (PM) equipped with the Home Monitoring (HM) technology (BIOTRONIK, Berlin, Germany) were enrolled. Based on the daily data transmission, all alarm alerts, all HM options changes and all AE were recorded with dated alert content and undertaken measures.Results: The study patients, followed up at least for one year, experienced 42 adverse events (AE), of which 26 were serious AE (SAE) and 3 SAE were defined as device-related (SAED). ICD patients (N=90) with concomitant coronary artery disease (CAD) had a statistically significantly higher SAE prevalence (p=0.0249). Patients with CRT-D had a lower SAE rate than patients with dual- or single-chamber ICD (р=0.046). Downloads of Home Monitoring parameters for retrospective mathematical analysis were available for 60 ICD patients, of which 47 had episodes of ventricular tachycardia (VT), ventricular fibrillation (VF) and/or atrial tachyarrhythmia (AT). Machine learning analysis of the trends of the physiologically meaningful parameters revealed correlations between changes and arrhythmia episodes, with the random forest and gradient boosting methods demonstrating the random effect of the results.Conclusion: Home Monitoring of CIED patients enables the evaluation of different devices applications and their clinical advantages. This might implement the prevention of adverse events and iatrogenic effects of pacing. Based on daily transmission of physiologically meaningful Home Monitoring parameters, the study results demonstrate the feasibility of developing a prediction algorithm for adverse events.