Chronic ischemic heart disease selection of treatment modality

The term stable ischemic heart disease (SIHD) often is used synonymously with chronic coronary artery disease (CAD) and encompasses a variety of conditions where the end result is a repetitive mismatch between myocardial oxygen supply and demand. This most frequently is seen when long-standing atherosclerotic obstruction within the epicardial coronary arteries results in poor flow and ischemia distally. However, this is not the only mechanism. Various pathophysiologic processes such as coronary artery vasospasm, microcirculation dysfunction, or congenital anomalies can cause the same supply-demand mismatch and result in chronic repetitive ischemia. Per the American College of Cardiology (ACC)/American Heart Association (AHA) 2012 guidelines, stable ischemic heart disease includes adults with known ischemic heart disease (IHD), who have stable pain syndromes (i.e., chronic angina), or those with new-onset, low-risk chest pain (i.e., low-risk, unstable angina or UA). Asymptomatic patients who were diagnosed through non-invasive methods or who have had their symptoms adequately controlled medically or the following revascularization are also considered to have stable ischemic heart disease. A distinction should be made between stable ischemic heart disease and acute coronary syndrome (ACS), where a more acute presentation with troponin elevation (i.e., myocardial infarction) or high-risk chest pain without troponin elevation (i.e., high-risk, UA) is required for the diagnosis. It also bears mentioning that stable ischemic heart disease patients can develop chronic, slow worsening of their angina symptoms, which is often managed medically, or may go on to develop ACS and require urgent intervention. Therefore, the ability to distinguish stable ischemic heart disease from ACS within the spectrum of atherosclerotic CAD is paramount

National trends and variability of atherectomy use for peripheral vascular interventions from 2010 to 2019

OBJECTIVES: Small, older studies suggest atherectomy devices have become common in peripheral vascular interventions (PVI) despite the paucity of strong clinical guidelines. We analyzed the 10-year trends in the use of atherectomy for PVI across the United States and identified main predictors of atherectomy use. METHODS: Using the Vascular Quality Initiative Registry, we identified all patients who had endovascular PVI for occlusive lower-extremity arterial disease from 2010 to 2019. Procedures in which an atherectomy device was recorded as the primary or secondary device were classified as the atherectomy group. We calculated frequency of atherectomy use over time and across geographic regions. Using regression modeling, we identified factors that were independently associated with atherectomy use. RESULTS: There were 205,377 procedures on 152,693 unique patients. Over 10 years, 16.6% of PVI procedures used atherectomy, increasing from 8.5% in 2010 to 19.7% in 2019, P \u3c0.0001. Across 17 geographic regions, there was a significant difference in the prevalence of atherectomy use, ranging from 8.2% to 29%. The strongest predictor of atherectomy use was the procedure being done in an office setting (OR 10.08, 95% CI 9.17-11.09) or ambulatory center (OR 4.0, 95% CI 3.65-4.39) vs hospital setting. The presence of severe (OR 2.6, 95% CI 2.4-2.85) or moderate (OR 1.5, 95% CI 1.4-1.69) lesion calcification was also predictive of atherectomy use. Other predictors included elective status, insurance provider, lesion length, prior PVI, claudication symptoms, and diabetes mellitus. CONCLUSIONS: Atherectomy use in PVI significantly increased between 2010 and 2019. There is wide regional variability in the use of atherectomy that seems to be driven more strongly by non-clinical factors