6 research outputs found
Coronary EndotheliumâDependent Vasomotor Function After DrugâEluting Stent and Bioresorbable Scaffold Implantation
Infarto de miocardio; DisfunciĂłn endotelial; TomografĂa de coherencia ĂłpticaMyocardial infarction; Endothelial dysfunction; Optical coherence tomographyInfart de miocardi; DisfunciĂł endotelial; Tomografia de coherĂšncia ĂČpticaBackground
Early generation drugâeluting stents (DESs) showed a high grade of coronary endothelial dysfunction that was attributed to lack of stent reendothelialization. Endotheliumâdependent vasomotor response of current DESs and bioresorbable scaffolds (BRSs) remains unknown. This study sought to assess the deviceârelated endothelial function of current devices and to correlate neointima healing with endothelial function.
Methods and Results
A total of 206 patients from 4 randomized trials treated with the durableâpolymer everolimusâeluting Xience (n=44), bioresorbableâpolymer sirolimusâeluting Orsiro (n=35), polymerâfree biolimusâeluting Biofreedom (n=24), bioactive endothelialâprogenitor cellâcapturing sirolimusâeluting Combo DES (n=25), polymerâbased everolimusâeluting Absorb (n=44), and Mgâbased sirolimusâeluting Magmaris BRS (n=34) underwent endotheliumâdependent vasomotor tests and optical coherence tomography imaging, as per protocol, at followâup. Crude vasomotor responses of distal segments to lowâdose acetylcholine (10â6 mol/L) were different between groups: bioresorbablepolymer DEShad the worst (â8.4%±12.6%) and durableâpolymer DES had the most physiologic (â0.4%±11.8%; P=0.014). Highâdose acetylcholine (10â4 mol/L) showed similar responses between groups (ranging from â10.8%±11.6% to â18.1%±15.4%; P=0.229). Device healing was different between devices. Uncovered struts ranged from 6.3%±7.1% (bioresorbableâpolymer DES) to 2.5%±4.5% (bioactive DES; P=0.056). In multivariate models, endotheliumâdependent vasomotor response was associated with age, bioresorbableâpolymer DES, and angiographic lumen loss, but not with strut coverage nor plaque type. Endothelial dysfunction (defined as â„4% vasoconstriction) was observed in 46.6% of patients with lowâdose and 68.9% with highâdose acetylcholine, without differences between groups.
Conclusions
At followâup, endothelial dysfunction was frequently observed in distal segments treated with current stents without remarkable differences between devices. Although neointima healing was different between devices, poor healing was not associated with endothelial dysfunction.The source funding of the 4 randomized trials included in this study is the following. The BVSâFLOW trial (Coronary vasomotor function and myocardial flow with bioresorbable vascular scaffolds or everolimusâeluting metallic stents: a randomised trial) was funded by a grant of âLa Maratoâ Foundation. The Spanish Heart Foundation funded the REâTROFI2 (LongâTerm Coronary Functional Assessment of the InfarctâRelated Artery Treated With EverolimusâEluting Bioresorbable Scaffolds or EverolimusâEluting Metallic Stents: Insights of the TROFI II Trial) and MAGSTEMI (MagnesiumâBased Resorbable Scaffold Versus Permanent Metallic SirolimusâEluting Stent in Patients With STâSegment Elevation Myocardial Infarction) trials. The FUNCOMBO (Coronary endothelial and microvascular function distal to polymerâfree and endothelial cellâcapturing drugâeluting stents) trial was funded by OrbusNeich and was promoted by the Spanish Heart Foundation
Usefulness of the Hybrid RFR-FFR Approach: Results of a Prospective and Multicenter Analysis of Diagnostic Agreement between RFR and FFRâThe RECOPA (REsting Full-Cycle Ratio Comparation versus Fractional Flow Reserve (A Prospective Validation)) Study
Cardiologia; Estudi fisiolĂČgic; EspanyaCardiologĂa; Estudio fisiolĂłgico; EspañaCardiology; Physiological study; SpainBackground. The resting fullâcycle ratio (RFR) is a novel resting index which in contrast to the gold standard (fractional flow reserve (FFR)) does not require maximum hyperemia induction. The objectives of this study were to evaluate the agreement between RFR and FFR with the currently recommended thresholds and to design a hybrid RFR-FFR ischemia detection strategy, allowing a reduction of coronary vasodilator use. Materials and Methods. Patients subjected to invasive physiological study in 9 Spanish centers were prospectively recruited between April 2019 and March 2020. Sensitivity and specificity studies were made to assess diagnostic accuracy between the recommended levels of RFR â€0.89 and FFR â€0.80 (primary objective) and to determine the RFR âgrey zoneâ in order to define a hybrid strategy with FFR affording 95% global agreement compared with FFR alone (secondary objective). Results. A total of 380 lesions were evaluated in 311 patients. Significant correlation was observed (R2â=â0.81; ) between the two techniques, with 79% agreement between RFRââ€â0.89 and FFRââ€â0.80 (positive predictive value, 68%, and negative predictive value, 80%). The hybrid RFR-FFR strategy, administering only adenosine in the âgrey zoneâ (RFR: 0.86 to 0.92), exhibited an agreement of over 95% with FFR, with high predictive values (positive predictive value, 91%, and negative predictive value, 92%), reducing the need for vasodilators by 58%. Conclusions. Dichotomous agreement between RFR and FFR with the recommended thresholds is significant but limited. The adoption of a hybrid RFR-FFR strategy affords very high agreement, with minimization of vasodilator use
Predictive Value of Cardiac Magnetic Resonance Feature Tracking after Acute Myocardial Infarction: A Comparison with Dobutamine Stress Echocardiography
EcocardiografĂa de seguimiento de manchas; DeformaciĂłn del miocardio; Seguimiento de caracterĂsticas de resonancia magnĂ©tica cardĂacaSpeckle-tracking echocardiography; Myocardial deformation; Cardiac magnetic resonance feature-trackingEcocardiografia de seguiment de taques; DeformaciĂł del miocardi; Seguiment de caracterĂstiques de ressonĂ ncia magnĂštica cardĂacaIn acute ST-segment elevation myocardial infarction (STEMI) late gadolinium enhancement (LGE) may underestimate segmental functional recovery. We evaluated the predictive value of cardiac magnetic resonance (CMR) feature-tracking (FT) for functional recovery and whether it incremented the value of LGE compared to low-dose dobutamine stress echocardiography (LDDSE) and speckle-tracking echocardiography (STE). Eighty patients underwent LDDSE and CMR within 5â7 days after STEMI and segmental functional recovery was defined as improvement in wall-motion at 6-months CMR. Optimal conventional and FT parameters were analyzed and then also applied to an external validation cohort of 222 STEMI patients. Circumferential strain (CS) was the strongest CMR-FT predictor and addition to LGE increased the overall accuracy to 74% and was especially relevant in segments with 50â74% LGE (AUC 0.60 vs. 0.75, p = 0.001). LDDSE increased the overall accuracy to 71%, and in the 50â74% LGE subgroup improved the AUC from 0.60 to 0.69 (p = 0.039). LGE + CS showed similar value as LGE + LDDSE. In the validation cohort, CS was also the strongest CMR-FT predictor of recovery and addition of CS to LGE improved overall accuracy to 73% although this difference was not significant (AUC 0.69, p = 0.44). Conclusion: CS is the strongest CMR-FT predictor of segmental functional recovery after STEMI. Its incremental value to LGE is comparable to that of LDDSE whilst avoiding an inotropic stress agent. CS is especially relevant in segments with 50â74% LGE where accuracy is lower and further testing is frequently required to clarify the potential for recovery.This research was supported by the Instituto de Salud Carlos III and co-funded by Fondo Europeo de Desarrollo Regional (FEDER) (grant numbers PI17/01836 and CIBERCV16/11/00486). JG and DM acknowledge financial support from the âAgencia Valenciana de la InnovaciĂłn, Generalitat Valencianaâ (grant) and from the âConselleria dâEducaciĂł, InvestigaciĂł, Cultura i Esport, Generalitat Valencianaâ (grant number AEST/2019/037)
Ajustando a RFR por Preditores de DiscordĂąncia, âA RFR Ajustadaâ: Uma Metodologia Alternativa para Melhorar a Capacidade DiagnĂłstica dos Ăndices Coronarianos
Angina de pecho; Reserva de flujo fraccional; SensibilidadAngina de pit; Reserva de flux fraccionari; SensibilitatAngina; Fractional flow reserve; SensitivityBackground
Cutoff thresholds for the âresting full-cycle ratioâ (RFR) oscillate in different series, suggesting that population characteristics may influence them. Likewise, predictors of discordance between the RFR and fractional flow reserve (FFR) have been documented. The RECOPA Study showed that diagnostic capacity is reduced in the RFR âgrey zoneâ, requiring the performance of FFR to rule out or confirm ischemia.
Objectives
To determine predictors of discordance, integrate the information they provide in a clinical-physiological index, the âAdjusted RFRâ, and compare its agreement with the FFR.
Methods
Using data from the RECOPA Study, predictors of discordance with respect to FFR were determined in the RFR âgrey zoneâ (0.86 to 0.92) to construct an index (âAdjusted RFRâ) that would weigh RFR together with predictors of discordance and evaluate its agreement with FFR.
Results
A total of 156 lesions were evaluated in 141 patients. Predictors of discordance were: chronic kidney disease, previous ischemic heart disease, lesions not involving the anterior descending artery, and acute coronary syndrome. Though limited, the âAdjusted RFRâ improved the diagnostic capacity compared to the RFR in the âgrey zoneâ (AUC-RFR = 0.651 versus AUC-âAdjusted RFRâ = 0.749), also showing an improvement in all diagnostic indices when optimal cutoff thresholds were established (sensitivity: 59% to 68%; specificity: 62% to 75%; diagnostic accuracy: 60% to 71%; positive likelihood ratio: 1.51 to 2.34; negative likelihood ratio: 0.64 to 0.37).
Conclusions
Adjusting the RFR by integrating the information provided by predictors of discordance to obtain the âAdjusted RFRâ improved the diagnostic capacity in our population. Further studies are required to evaluate whether clinical-physiological indices improve the diagnostic capacity of RFR or other coronary indices
Polymer-free sirolimus-eluting stent use in Europe and Asia: Ethnic differences in demographics and clinical outcomes
International audienceThe objective of this study was to assess regional and ethnic differences in an unselected patient population treated with polymer-free sirolimus-eluting stents (PF-SES) in Asia and Europe.Methods: Two all-comers observational studies based on the same protocol (ClinicalTrials.gov Identifiers: NCT02629575 and NCT02905214) were combined for data analysis to assure sufficient statistical power. The primary endpoint was the accumulated target lesion revascularization (TLR) rate at 9-12 months.Results: Of the total population of 7243 patients, 44.0% (3186) were recruited in the Mediterranean region and 32.0% (2317) in central Europe. The most prominent Asian region was South Korea (17.6%, 1274) followed by Malaysia (5.7%, 413). Major cardiovascular risk factors varied significantly across regions. The overall rates for accumulated TLR and MACE were low with 2.2% (140/6374) and 4.4% (279/6374), respectively. In ACS patients, there were no differences in terms of MACE, TLR, MI and accumulated mortality between the investigated regions. Moreover, dual antiplatelet therapy (DAPT) regimens were substantially longer in Asian countries even in patients with stable coronary artery disease as compared to those in Europe.Conclusions: PF-SES angioplasty is associated with low clinical event rates in all regions. Further reductions in clinical event rates seem to be associated with longer DAPT regimens
CT or Invasive Coronary Angiography in Stable Chest Pain.
Background: In the diagnosis of obstructive coronary artery disease (CAD), computed tomography (CT) is an accurate, noninvasive alternative to invasive coronary angiography (ICA). However, the comparative effectiveness of CT and ICA in the management of CAD to reduce the frequency of major adverse cardiovascular events is uncertain.
Methods: We conducted a pragmatic, randomized trial comparing CT with ICA as initial diagnostic imaging strategies for guiding the treatment of patients with stable chest pain who had an intermediate pretest probability of obstructive CAD and were referred for ICA at one of 26 European centers. The primary outcome was major adverse cardiovascular events (cardiovascular death, nonfatal myocardial infarction, or nonfatal stroke) over 3.5 years. Key secondary outcomes were procedure-related complications and angina pectoris.
Results: Among 3561 patients (56.2% of whom were women), follow-up was complete for 3523 (98.9%). Major adverse cardiovascular events occurred in 38 of 1808 patients (2.1%) in the CT group and in 52 of 1753 (3.0%) in the ICA group (hazard ratio, 0.70; 95% confidence interval [CI], 0.46 to 1.07; P = 0.10). Major procedure-related complications occurred in 9 patients (0.5%) in the CT group and in 33 (1.9%) in the ICA group (hazard ratio, 0.26; 95% CI, 0.13 to 0.55). Angina during the final 4 weeks of follow-up was reported in 8.8% of the patients in the CT group and in 7.5% of those in the ICA group (odds ratio, 1.17; 95% CI, 0.92 to 1.48).
Conclusions: Among patients referred for ICA because of stable chest pain and intermediate pretest probability of CAD, the risk of major adverse cardiovascular events was similar in the CT group and the ICA group. The frequency of major procedure-related complications was lower with an initial CT strategy. (Funded by the European Union Seventh Framework Program and others; DISCHARGE ClinicalTrials.gov number, NCT02400229.)