Prognostic effect of beta-adrenergic receptor blockades in patients with coronary artery disease undergoing contemporary percutaneous coronary intervention: A nationwide cohort study

배경: 베타-아드레날린 수용체 차단제는 심장에 대한 과도한 아드레날린 활성에 따른 유해한 영향을 감소시키기 위하여 관상 동맥 질환 환자에서 사용되어 왔다. 그러나, 관상동맥 중재술 및 이후의 현대적인 약물치료의 배경하에서 베타차단제의 임상 효과에 대한 증거는 부족하다. 방법: 우리나라의 건강보험심사평가원 자료를 바탕으로 2011년부터 2015년까지 심근경색 (30,404명) 또는 협심증 (48,617명)을 최초 진단받아 경피적 관상동맥 중재시술을 받은 환자를 대상으로 하였다. 성향 점수 매칭 분석을 사용하여 베타 차단제 치료를 받은 환자와 받지 않은 환자에서 사망률을 비교하였다. 결과: 베타 차단제는 협심증 환자 (62.7%)보다 심근경색 환자 (83.4%)에서 더 높은 비율로 사용되었다. 2.1년의 추적 관찰 기간 동안, 전체 환자에서의 사망률은 베타 차단제 사용군에서 사용하지 않은 군에 비해 유의하게 낮았다 (2년 사망률: 베타 차단제 사용군 4.2%, 베타 차단제 비사용군 4.7%; p=0.005). 성향 점수 매칭 분석에서 진단에 따른 예후 차이를 보였는데, 심근경색 코호트에서 베타 차단제 치료군에서 사망의 위험이 유의하게 낮았으며 (위험비: 0.74; 95 % 신뢰 구간 : 0.63-0.86; p <0.001), 혐심증 코호트에서는 차이를 보이지 않았다 (위험비: 1.04; 95 % 신뢰구간: 0.94–1.15; p=0.44). 베타 차단제와 관련된 생존증가 효과는 심근경색 사건 후 1년 이내에 가장 컸다. 결론: 관상동맥 중재술 및 현대적인 시술 후 약물치료를 받은 선택되지 않은 관상동맥질환 환자에서 베타 차단제 치료는 심근경색 환자에서 사망률의 유의한 감소와 관련이 있었지만 협심증 환자에서는 그렇지 않았다.|Background: Beta-adrenergic receptor blockers are used in patients with coronary artery disease (CAD) to reduce the deleterious effects of excessive adrenergic activation on the heart. However, there is limited evidence regarding the benefit of beta-blockers in the context of contemporary management following percutaneous coronary intervention (PCI). Methods: The nationwide South Korea National Health Insurance database was used to identify 79,021 patients with a diagnosis of either acute myocardial infarction (AMI; n = 30,404) or angina pectoris (n = 48,617) who underwent PCI between 2011 and 2015, and survived to be discharged from hospital. The risk of all-cause mortality in patients treated with a beta-blocker was compared with those who did not receive beta-blocker therapy using a propensity-score matching analysis. Results: Beta-blockers were used in a higher proportion of patients with AMI (83.4%) than those with angina pectoris (62.7%). Over a median follow-up of 2.1 years (interquartile range, 1.2–3.2 years), the risk of death was comparable between the two groups in the overall population (hazard ratio [HR]: 0.98; 95% confidence interval [CI]: 0.90–1.06; p = 0.58). However, the mortality risk was significantly lower in patients treated with a beta-blocker in the AMI group (HR: 0.74; 95% CI: 0.63–0.86; p < 0.001). In the angina group, the mortality risk was comparable regardless of beta-blocker use (HR: 1.04; 95% CI: 0.94–1.15; p = 0.44). The survival benefit associated with beta-blocker therapy was most significant in the first year after the AMI event. Conclusions: In unselected CAD patients who underwent contemporary post-PCI management, beta-blocker treatment was associated with a significant reduction in mortality in patients with AMI but not in those with angina.Docto

Quantitative Coronary Angiography Guidance for Drug-Eluting Stent Implantation: A Narrative Review

Background Percutaneous coronary intervention (PCI) using drug-eluting stents is an established strategy for the treatment of significant obstructive coronary artery disease. Evidence supports that intravascular imaging-guided PCI offers advantages over conventional angiography-guided PCI, though its use is limited, likely due to high costs. Angiography-guided PCI relies on visual estimation, leading to inter- and intra-observer variability and suboptimal outcomes. Quantitative coronary angiography (QCA) provides reliable information about vascular dimensions, overcoming these limitations. Poststenting postdilation with appropriately sized noncompliant balloons improves outcomes by increasing lumen area and reducing stent malapposition. Aims We investigated the procedural details of each modality used to guide PCI and assessed the utility of QCA-guided PCI with routine postdilation when intravascular imaging is unavailable. Methods and Results A systematic search was conducted from inception to May 31, 2024, identifying nine randomized controlled trials (with over 500 patients) that compared outcomes of PCI guided by intravascular imaging versus conventional angiography or QCA. The findings indicate that intravascular imaging guidance significantly improves clinical outcomes compared to angiography guidance. Notably, QCA-guided PCI with routine postdilation yielded outcomes comparable to those achieved with intravascular imaging-guided PCI. Conclusions QCA-guided PCI with routine postdilation may be a viable alternative for improving PCI outcomes, especially in settings where intravascular imaging is unavailable

Comparison of empagliflozin and sitagliptin therapy on myocardial perfusion reserve in diabetic patients with coronary artery disease

Background Sodium-glucose co-transporter 2 inhibitors reduce the risk of cardiovascular events in type 2 diabetic patients with coronary artery disease (CAD); however, the underlying mechanisms remain unclear. Objectives We compared the effects of empagliflozin vs. sitagliptin therapy on myocardial perfusion reserve (MPR) using dynamic single-photon emission computed tomography (SPECT) imaging. Methods In total, 100 patients with type 2 diabetes, CAD and an MPR <2.5 were randomized to receive either empagliflozin (10 mg once daily) or sitagliptin (100 mg once daily). Dynamic SPECT examinations were performed at baseline and at 6 months. The primary endpoint was the percent change of global MPR. Evaluable SPECT data were available for 98 patients. Results Baseline clinical characteristics and SPECT data were well balanced between the two groups. At a 6-month follow-up, the fasting glucose and glycated hemoglobin levels significantly decreased in both groups. Hematocrit and hemoglobin levels significantly increased in the empagliflozin group but not in the sitagliptin group. The global MPR significantly improved after treatment in both groups (34.5 +/- 70.6%; P = 0.005 for empagliflozin vs. 22.4 +/- 45.7%; P = 0.024 for sitagliptin). However, there was no significant difference in the global MPR between the two groups (P = 0.934). Similar findings were detected with regard to the regional MPR. Conclusion Among patients with type 2 diabetes and CAD, both empagliflozin and sitagliptin significantly improved the global MPR with no significant difference between the groups

Comparison of simple versus complex stenting in patients with true distal left main bifurcation lesions

Introduction: Distal left main (LM) bifurcation disease is one of the most challenging lesion subsets for percutaneous coronary intervention (PCI) and optimal stenting strategy for such complex lesions is still debated. This study aimed to compare clinical outcomes following single versus dual stenting for true distal LM bifurcation lesions. Methods: Patients with true distal LM bifurcation lesions (type 1,1,1 or 0,1,1: both left anterior descending and circumflex artery >2.5 mm diameter) receiving PCI with drug-eluting stents (DES) from two large clinical registries were evaluated. The primary outcome was target-lesion failure (TLF), defined as a composite of cardiac death, target-vessel myocardial infarction (MI), or target-lesion revascularization (TLR). Outcomes were compared with the use of propensity scores and inverse probability-weighting adjustment to reduce treatment selection bias. Results: Among 1,002 patients undergoing true distal LM PCI, 440 (43.9%) and 562 (56.1%) were treated with single and dual stents, respectively. The TLF rates at 3 year was 20.3% in the single-stent group and 24.1% in the dual-stenting group (log-rank p = 0.18). The adjusted risk for TLF did not differ significantly between two groups (hazard ratio [HR] with dual-stent vs. single-stent: 1.27, 95% confidence interval [CI]: 0.95?1.71). The adjusted risks for death, MI, repeat revascularization, or stent thrombosis were also similar between the single- and dual-stenting groups. Conclusions: In patients undergoing PCI for true distal LM disease, single- and dual-stent strategies showed a similar adjusted risk of TLF at 3 years. Our findings should be confirmed or refuted through large, randomized clinical trials

Ten-year outcomes of early generation sirolimus- versus paclitaxel-eluting stents in patients with left main coronary artery disease

To compare 10-year outcomes after implantation of sirolimus-eluting stents (SES) versus paclitaxel-eluting stents (PES) for left main coronary artery (LMCA) stenosis. Very long-term outcome data of patients with LMCA disease treated with drug-eluting stents (DES) have not been well described. In 10-year extended follow-up of the MAINCOMPARE registry, we evaluated 778 patients with unprotected LMCA stenosis who were treated with SES (n = 607) or PES (n = 171) between January 2000 and June 2006. The primary composite outcome (a composite of death, myocardial infarction [MI] or target-vessel revascularization [TVR]) was compared with an inverse-probability-of-treatment-weighting (IPTW) adjustment. Clinical events have linearly accumulated over 10 years. At 10 years, there were no significant differences between SES and PES in the observed rates of the primary composite outcome (42.0% vs. 47.4%; hazard ratio [HR] 0.85; 95% confidence interval [CI] 0.66-1.10), and definite stent thrombosis (ST) (1.9% vs. 1.8%; HR 1.02, 95% CI 0.28-3.64). In the IPTW-adjusted analyses, there were no significant differences between SES and PES in the risks for the primary composite outcome (HR 0.89, 95% CI 0.65-1.14) or definite ST (adjusted HR 1.05, 95% CI 0.29-3.90). In patients who underwent DES implantation, high overall adverse clinical event rates (with a linearly increasing event rate over time) were observed during extended follow-up. At 10 years, there were no measurable differences in outcomes between patients treated with SES vs. PES for LMCA disease. The incidence of stent thrombosis was quite low and comparable between the groups

Statin/ezetimibe combination therapy vs statin monotherapy for carotid atherosclerotic plaque inflammation

It remains uncertain whether statin/ezetimibe combination therapy serves as a useful and equivalent alternative to statin monotherapy for reducing atherosclerotic plaque inflammation. The aim of the present study was to compare the effects of statin/ezetimibe combination therapy and statin monotherapy on carotid atherosclerotic plaque inflammation using F-18-fluorodeoxyglucose ((18)FDG) positron emission tomography (PET)/computed tomography (CT) imaging. Data were pooled from 2 clinical trials that used serial (18)FDG PET/CT examination to investigate the effects of cholesterol-lowering therapy on carotid atherosclerotic plaque inflammation. The primary outcome was the percent change in the target-to-background ratio (TBR) of the index vessel in the most diseased segment (MDS) at 6-month follow-up. Baseline characteristics were largely similar between the 2 groups. At the 6-month follow-up, the MDS TBR of the index vessel significantly decreased in both groups. The percent change in the MDS TBR of the index vessel (primary outcome) did not differ significantly between the 2 groups (-8.41 +/- 15.9% vs -8.08 +/- 17.0%, respectively, P = .936). Likewise, the percent change in the whole vessel TBR of the index vessel did not differ significantly between the 2 groups. There were significant decreases in total and LDL cholesterol levels in both groups at follow-up (P < .001). There were no significant correlations between the percent changes in MDS TBR of the index vessel, changes in the lipid, and high-sensitive C-reactive protein levels. The reduction in carotid atherosclerotic plaque inflammation by statin/ezetimibe combination therapy was equivalent to that by the statin monotherapy

Prevalence, predictors, prognostic significance, and effect of techniques on outcomes of coronary lesion calcification following implantation of drug-eluting stents: a patient-level pooled analysis of stent-specific, multicenter, prospective IRIS-DES registries

Aims There is limited information on the clinical relevance and procedural impact of coronary artery calcification (CAC) in the contemporary percutaneous coronary intervention (PCI) setting. This study sought to determine the incidence and clinical significance of procedural techniques on the outcomes in 'real-world' patients with CAC undergoing PCI with drug-eluting stents (DESs). Methods and results Using patient-level data from seven stent-specific, prospective DES registries, we evaluated 17 084 patients who underwent PCI with various DES types between July 2007 and July 2015. The primary outcome was target-vessel failure (TVF), defined as a composite of cardiac death, target-vessel myocardial infarction, or target-vessel revascularization. Outcomes through 3 years (and between 0-1 and 1-3 years) were assessed according to CAC status (none/mild vs. moderate/severe) and stenting technique (predilation or post-dilation). Among 17 084 patients with 22 739 lesions included in the pooled dataset, moderate to severe CAC was observed in 11.3% of patients (10.1% of lesions). Older age, lower BMI, diabetes, hypertension, family history of coronary artery disease, and renal failure were independent predictors of moderate/severe CAC. The presence of moderate/severe CAC was significantly associated with an adjusted risk of TVF at 3 years [hazard ratio, 1.37; 95% confidence interval (CI), 1.19-1.58; P < 0.001]. For severe CAC, optimal lesion preparation with predilation was associated with a lower 3-year rate of TVF (no vs. yes, 22.3 vs. 12.8%), in which the effect of predilation was prominent at the late period of 1-3 years (hazard ratio, 0.28; 95% CI, 0.12-0.69; P = 0.003) than at the early period through 1 year (hazard ratio, 1.16; 95% CI, 0.37-3.71; P = 0.80). However, post-dilation (with a high-pressure noncompliant balloon) had no effect on the outcome. Conclusions In this study, moderate/severe CAC was common (similar to 10%) and strongly associated with TVF during 3 years of follow-up. For severe CAC, optimal lesion preparation with pre-balloon dilation has a significant effect on long-term outcomes, especially during the late period beyond 1 year. Clinical Trial Registration - URL: http://www.clinicaltrials.gov. Unique identifier: NCT01186133. Coron Artery Dis 32: 42-50 Copyright (c) 2020 Wolters Kluwer Health, Inc. All rights reserved