Drug-coated balloon: an effective alternative to stent strategy in small-vessel coronary artery disease—a meta-analysis

BackgroundSmall-vessel coronary artery disease (CAD) is frequently observed in coronary angiography and linked to a higher risk of lesion failure and restenosis. Currently, treatment of small vessels is not standardized while having drug-eluting stents (DES) or drug-coated balloons (DCBs) as possible strategies. We aimed to conduct a meta-analytic approach to assess the effectiveness of treatment strategies and outcomes for small-vessel CAD.MethodsComprehensive literature search was conducted using PubMed, Embase, MEDLINE, and Cochrane Library databases to identify studies reporting treatment strategies of small-vessel CAD with a reference diameter of ≤3.0 mm. Target lesion revascularization (TLR), target lesion thrombosis, all-cause death, myocardial infarction (MI), and major adverse cardiac events (MACE) were defined as clinical outcomes. Outcomes from single-arm and randomized studies based on measures by means of their corresponding 95% confidence intervals (CI) were compared using a meta-analytic approach. Statistical significance was assumed if CIs did not overlap.ResultsThirty-seven eligible studies with a total of 31,835 patients with small-vessel CAD were included in the present analysis. Among those, 28,147 patients were treated with DES (24 studies) and 3,299 patients with DCB (18 studies). Common baseline characteristics were equally distributed in the different studies. TLR rate was 4% in both treatment strategies [0.04; 95% CI 0.03–0.05 (DES) vs. 0.03–0.07 (DCB)]. MI occurred in 3% of patients receiving DES and in 2% treated with DCB [0.03 (0.02–0.04) vs. 0.02 (0.01–0.03)]. All-cause mortality was 3% in the DES group [0.03 (0.02–0.05)] compared with 1% in the DCB group [0.01 (0.00–0.03)]. Approximately 9% of patients with DES developed MACE vs. 4% of patients with DCB [0.09 (0.07–0.10) vs. 0.04 (0.02–0.08)]. Meta-regression analysis did not show a significant impact of reference vessel diameter on outcomes.ConclusionThis large meta-analytic approach demonstrates similar clinical and angiographic results between treatment strategies with DES and DCB in small-vessel CAD. Therefore, DES may be waived in small coronary arteries when PCI is performed with DCB

Impact of extent of coronary artery disease and percutaneous revascularization assessed by the SYNTAX score on outcomes following transcatheter aortic valve replacement

Objectives!#!The aim of the study was to analyze the impact of concomitant coronary artery disease (CAD) assessed by the SYNTAX score (SS) and periprocedural percutaneous coronary intervention (PCI) on outcomes after transcatheter aortic valve replacement (TAVR).!##!Background!#!Due to controversial data regarding the effect of CAD on outcomes after TAVR, proper revascularization strategies remain a matter of debate.!##!Methods!#!553 patients with severe aortic stenosis undergoing TAVR were included in this study. SS was calculated for each patient at baseline and after PCI. Primary outcome was one-year all-cause mortality.!##!Results!#!60.2% of patients (N = 333) exhibited CAD with a mean SS of 10.8 ± 8.8. Of those, 120 patients (36.0%) received periprocedural PCI. In the treatment group, mean SS was decreased from 14.9 ± 9.1 to 6.3 ± 6.7. Patients with concomitant CAD suffered more frequently from myocardial infarction (MI) post TAVR compared to those without CAD (2.1% vs. 0.0%; P < 0.01). In the CAD cohort, MI rates were comparable between patients with and without PCI (2.2% vs. 2.5%; P = 0.71). Regarding SS, patients with a residual SS < 8 showed significant lower rates of one-year mortality (9.0% vs. 18.2%; P = 0.016) and MACCE (16.5% vs. 32.2%; P = 0.001). Besides left bundle brunch, predictors for an increased one-year mortality were a residual SS ≥ 8 in the CAD group (OR = 3.17; P = 0.011) and a EuroSCORE ≥ 4% in the entire study population (OR = 2.18; P = 0.017).!##!Conclusion!#!Our results suggest that a residual SS-guided revascularization strategy may improve prognosis after TAVR in patients with concomitant CAD. PCI aiming for a residual SS < 8 was associated with improved one-year clinical outcomes

Predictors of worse outcome after postponing non-emergency cardiac interventions during the COVID-19 pandemic

Objective Deferral of non-emergency cardiac procedures is associated with increased early emergency cardiovascular hospitalisation. This study aimed to identify predictors of worse clinical outcome after deferral of non-emergency cardiovascular interventions.Methods This observational case-control study included consecutive patients whose non-emergency cardiac intervention has been postponed during COVID-19-related lockdown between 19 March and 30 April 2020 (n=193). Cox regression was performed to identify predictors of the combined 1-year end point emergency cardiovascular hospitalisation and death. All patients undergoing non-emergency interventions in the corresponding time period 2019 served as control group (n=216).Results The combined end point of death and emergency cardiovascular hospitalisation occurred in 70 (36.3%) of 193 patients with a postponed cardiovascular intervention. The planned intervention was deferred by a median of 23 (19–36) days. Arterial hypertension (HR 2.27; 95% CI 1.00 to 5.12; p=0.049), chronic kidney disease (HR 1.89; 95% CI 1.03 to 3.49; p=0.041) as well as severe valvular heart disease (HR 3.08; 95% CI 1.68 to 5.64; p<0.001) were independent predictors of death or emergency hospitalisation. Kaplan-Maier estimators of the combined end point were 31% in patients with arterial hypertension, 56% in patients with severe valvular heart disease and 77% with both risk factors (HR 12.4, 95% CI 3.8 to 40.7; p<0.001) and only 9% in patients without these risk factors (log rank p<0.001). N-terminal pro-B-type natriuretic peptide (NT-proBNP) cut-point of ≥1109 pg/mL best predicts the occurrence of primary end point event in deferred patients (area under the curve 0.71; p<0.001; sensitivity 63.8%, specificity 69.4%).Conclusion Our results suggest that patients with either arterial hypertension, chronic kidney or severe valvular heart disease are at very high risk for emergency hospitalisation and increased mortality in case of postponed cardiac interventions even in supposed stable clinical status. Risk seems to be even higher in patients suffering from a combination of these conditions. If the ongoing or future pandemics force hospitals again to postpone cardiac interventions, the biomarker NT-proBNP is an applicable parameter for outpatient monitoring to identify those at risk for adverse cardiovascular events

Deferral of Non-Emergency Cardiovascular Interventions Triggers Increased Cardiac Emergency Admissions—Analysis of the COVID-19 Related Lockdown

Background: Data on the relation between non-emergency and emergency cardiac admission rates during the COVID-19 lockdown and post-lockdown period are sparse. Methods: Consecutive cardiac patients admitted to our tertiary heart center between 1 January and 30 June 2020 were included. The observation period of 6 months was analyzed in total and divided into three defined time periods: the pre-lockdown (1 January–19 March), lockdown (20 March–19 April), and post-lockdown (20 April–30 June) period. These were compared to the reference periods 2019 and 2022 using daily admission rates and incidence rate ratios (IRR). Results: Over the observation period from 1 January to 30 June, cardiac admissions (including non-emergency and emergency) were comparable between 2019, 2020, and 2022 (n = 2889, n = 2952, n = 2956; p = 0.845). However, when compared to the reference period 2019, non-emergency admissions decreased in 2020 (1364 vs. 1663; p = 0.02), while emergency admissions significantly increased (1588 vs. 1226; p < 0.001). Further analysis of the lockdown period revealed that non-emergency admissions dropped by 82% (IRR 0.18; 95%-CI 0.14–0.24; p < 0.001) and 42% fewer invasive cardiac interventions were performed (p < 0.001), whereas the post-lockdown period showed a 52% increase of emergency admissions (IRR 1.47; 95%-CI 1.31–1.65; p < 0.001) compared to 2019. Conclusions: We demonstrate a drastic surge of emergency cardiac admissions post-COVID-19 related lockdown suggesting that patients who did not keep their non-emergency appointment had to be admitted as an emergency later on