Efficacy and Safety of Polymer-Free Ultrathin Strut Sirolimus-Probucol Coated Drug-Eluting Stents for Chronic Total Occlusions: Insights from the Coroflex ISAR 2000 Worldwide Registry

Objective. Coronary revascularization in chronic total occlusion (CTO) is associated with improved clinical outcomes. The choice of the coronary stent is crucial in maintaining long-term vessel patency after CTO revascularization. We investigated the efficacy and safety of polymer-free ultrathin strut sirolimus-probucol coated drug-eluting stents (PF-SES) for CTO lesions. Methods. Patients with CTO lesions treated with PF-SES were identified from the prospective multicenter international ISAR 2000 registry. The primary endpoint was clinically driven target lesion revascularization (TLR) at 9 months. Secondary endpoints were 9-month major adverse cardiac events (death, myocardial infarction, or TLR) (MACE) and the occurrence of stent thrombosis. Results. A total of 111 patients with CTO lesions (n=127) were available for analysis. The 9-month clinical follow-up rate was 91%. The mean reference vessel diameter and lesion length were 2.76 mm ± 0.40 and 26.8 mm ± 13.1, respectively. The overall DAPT duration was 9.7 ± 2.8 months. Only one (1%) in-hospital MI was reported. The TLR and MACE rates at 9 months were 2% (2/101) and 5.9% (6/101), respectively. The 9-month accumulated rates of definite or probable stent thrombosis was 0% (0/101). Conclusion. Revascularizations for CTO with PF-SES are associated with low rates of TLR and MACE at 9 months with no stent thrombosis. These initial findings need to be compared with results of other new generation DES of larger studies

The effect of care pathways on coronary care nurses: a preliminary study

Abstract Background and Objectives: A care pathway is a structured care plan based on best clinical practice for a particular patient group. It reorganizes a complex process by providing structured, standardized care and supportive multidisciplinary teamwork. Although care pathways are used worldwide, the impact and benefit of a care pathway for coronary care practices have been minimally debated. This preliminary study aimed to examine the effect of a care pathway on the autonomy, teamwork, and burnout levels among coronary care nurses in a tertiary hospital. Methods: A preliminary study was conducted using a pre/posttest one-group quasi-experimental design. A self-administered questionnaire was provided to 37 registered nurses from the cardiac ward of a tertiary hospital. The care pathway was developed on the basis of the current literature, local guidelines, and expert panel advice. The autonomy, teamwork, and burnout levels at the beginning and 4 months after disseminating the care pathway were measured. Implementing the care pathway included educational sessions, training in using the care pathway, and site visits to monitor nursing practices. Results: Most of the respondents were female (94.6%; n = 35), the median age of the respondents was 26.5 years (interquartile range [IQR] = 23-31), and the median length of the clinical experience was 4 years (IQR = 2-8). A statistically significant reduction in the mean burnout score was observed (mean of 58.12 vs 52.69, P < .05). A slight improvement in autonomy level was found, although it was not statistically significant. No statistically significant improvement was found in the teamwork levels. Conclusion: The care pathway was associated with reduced nurse burnout. The results showed a slight improvement in autonomy level among coronary care nurses after implementing the care pathway. From a practical viewpoint, the current study can help policy makers and managers reduce burnout. This study highlights the importance of using care pathways as a tool to reorganize the care process and improve the working environment. Managers must support nursing decisions and provide continuous education to enhance nurses' autonomy, which may increase understanding of respective roles, leading to higher levels of teamwork. However, with a small sample size, caution must be applied, as the findings might not be generalizable

Trends and variations in the prescribing of secondary preventative cardiovascular therapies for non-ST elevation myocardial infarction (NSTEMI) in Malaysia

Purpose: Information is lacking on prescribing of preventative cardiovascular pharmacotherapies for patients with non-ST elevation myocardial infarction (NSTEMI) in the Asian region. This study examined the prescribing rate of these pharmacotherapies, comparing NSTEMI to STEMI, and variations across demographics and clinical factors within the NSTEMI group in the multi-ethnic Malaysian population. Methods: This is a retrospective analysis of the Malaysian National Cardiovascular Disease Database-Acute Coronary Syndrome registry from year 2006 to 2013 (n = 30,873). On-discharge pharmacotherapies examined were aspirin, ADP-antagonists, statins, ACE-inhibitors, angiotensin-II-receptor blockers, and beta-blockers. Multivariate logistic regression was used to calculate adjusted odds ratio of receiving individual pharmacotherapies according to patients’ characteristics in NSTEMI patients (n = 11,390). Results: Prescribing rates for cardiovascular pharmacotherapies had significantly increased especially for ADP-antagonists (76%) in NSTEMI patients. More than 85% were prescribed statins and antiplatelets but rates remained significantly lower compared to STEMI. Women and those over 65 years old were less likely to be prescribed these pharmacotherapies compared to men and younger NSTEMI patients. Chinese and Indians were more likely to receive selected pharmacotherapies compared to Malays (main ethnicity). Geographical variations were observed; East Malaysian (Malaysian Borneo) patients were less likely to receive these compared to Western region of Malaysian Peninsular. Underprescribing in patients with risk factors such as diabetes were observed with other co-morbidities influencing prescribing selectively. Conclusion: This study uncovers demographic and clinical variations in cardiovascular pharmacotherapies prescribing for NSTEMI. Concerted efforts by policy makers, specialty societies, and physicians are required focusing on elderly, women, Malays, East Malaysians, and high-risk patients

In-hospital mortality of cardiogenic shock complicating ST-elevation myocardial infarction in Malaysia: a retrospective analysis of the Malaysian National Cardiovascular Database (NCVD) registry

Objectives Cardiogenic shock (CS) complicating ST-elevation myocardial infarction (STEMI) carries an extremely high mortality. The clinical pattern of this life threatening complication has never been described in Malaysian setting. This study is to investigate the incidence, clinical characteristics and outcome of STEMI patients with CS in our population. Design A retrospective analysis of STEMI patients from 18 hospitals across Malaysia contributing to the Malaysian National Cardiovascular Database-acute coronary syndrome) registry (NCVD-ACS) year 2006-2013. Participants 16 517 patients diagnosed of STEMI from 18 hospitals in Malaysia from the year 2006 to 2013. Primary outcome measures In-hospital and 30 day post-discharge mortality. Results CS complicates 10.6% of all STEMIs in this study. They had unfavourable premorbid conditions and poor outcomes. The in-hospital mortality rate was 34.1% which translates into a 7.14 times mortality risk increment compared with STEMI without CS. Intravenous thrombolysis remained as the main urgent reperfusion modality. Percutaneous coronary interventions (PCI) in CS conferred a 40% risk reduction over non-invasive therapy but were only done in 33.6% of cases. Age over 65, diabetes mellitus, hypertension, chronic lung and kidney disease conferred higher risk of mortality. Conclusion Mortality rates of CS complicating STEMI in Malaysia are high. In-hospital PCI confers a 40% mortality risk reduction but the rate of PCI among our patients with CS complicating STEMI is still low. Efforts are being made to increase access to invasive therapy for these patients. © 2019 Author(s) (or their employer(s)). Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ

Inverse changes in plasma tetranectin and titin levels in patients with type 2 diabetes mellitus: a potential predictor of acute myocardial infarction?

An early intervention using biomarkers to predict acute myocardial infarction (AMI) will effectively reduce global heart attack incidence, particularly among high-risk patients with type 2 diabetes mellitus (T2DM). This study attempted to identify potential biomarkers by detecting changes in the levels of plasma proteins in T2DM patients following onset of AMI in comparison with those without AMI. Volunteer T2DM patients without AMI (control; n=10) and T2DM patients with AMI (n=10) were recruited. Plasma samples from these patients were evaluated via two-dimensional gel electrophoresis (2DE) to screen for proteins with level changes between the two groups. The abundance of spots on gel images was analyzed using Progenesis SameSpots and subjected to false discovery rate (FDR) analysis. Protein spots with statistically significant changes of at least 1.5 fold were selected for mass spectrometry (MS) analysis. Due to strong cardiac connections, tetranectin and titin were evaluated by enzymelinked immunosorbent assay (ELISA). The adjusted P-values and fold changes between the two groups resulted in identification of 34 protein spots with significantly altered abundance. Upon MS analysis, 17 plasma proteins were identified: tetranectin, titin, clusterin, haptoglobin, myosin-13, zinc fnger protein 445, DNA repair protein RAD50, serum albumin, apolipoprotein A-IV, caspase-6, aminoacyl tRNA synthase complex-interacting multifunctional protein 1, serotransferrin, retinol-binding protein 4, transthyretin, alpha-1-antitrypsin, apolipoprotein A-I and serum amyloid A. Comparable patterns of changes in tetranectin and titin between the control and AMI groups were confirmed using ELISA. In summary, tetranectin and titin in plasma appeared to be closely associated with the onset of AMI among T2DM patients and can be used as potential biomarkers for prediction of a cardiac event, though this requires validation in a prospective cohort study

Characteristics and short-term outcomes of young women with acute myocardial infarction in Malaysia: a retrospective analysis from the Malaysian National Cardiovascular Database registry

Objective Young women form a minority but an important group of patients with acute myocardial infarction (MI) as it can potentially cause devastating physical and socioeconomic impact. This study was aimed to investigate the characteristics and outcomes of young women with MI in Malaysia. Design This is a retrospective analysis of women with ST-elevation MI (STEMI) and non-STEMI (NSTEMI) from 18 hospitals across Malaysia using the Malaysian National Cardiovascular Database registry-acute coronary syndrome (NCVD-ACS). Participants Women patients diagnosed with acute MI from year 2006 to 2013 were identified and divided into young (age ≤ 45, n=292) and older women (age >45, n=5580). Primary outcome measure Comparison of demographics, clinical characteristics and in-hospital management was performed between young and older women. In-hospital and 30-day all-cause mortality were examined. Results Young women (mean age 39±4.68) made up 5% of women with MI and were predominantly of Malay ethnicities (53.8%). They have a higher tendency to present as STEMI compared with older women. Young women have significantly higher rates of family history of premature coronary artery disease (CAD) (20.5% vs 7.8% p80% prescribed statins and aspirin. The all-cause mortality rates of young women were lower for both in-hospital and 30 days, especially in those with STEMI with adjusted mortality ratio to the older group, was 1:9.84. Conclusion Young women with MI were over-represented by Malays and those with a family history of premature CAD. Preventive measures are needed to reduce cardiovascular risks in young women. Although in-hospital management was similar, short-term mortality outcomes favoured young compared with older women. © © Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ

Percutaneous Transvenous Mitral Commissurotomy in patients with rheumatic heart disease: a hospital-based retrospective study

Background: Percutaneous Transvenous Mitral Commissurotomy (PTMC) is a procedure of choice for the treatment of severe mitral stenosis. We aimed to describe our experiences on management of rheumatic heart disease with PTMC in Malaysia. Methods: Patients who underwent PTMC were traced through the electronic medical record of University Malaya Medical Centre. The patients detailed echocardiogram parameter pre-procedure, post-procedure and outcome were documented. Statistical analysis was performed using SPSS version on 18 for windows. Results: 11 patients were treated with PTMC in our centre with 90.9% (n=10) success rate. Subjects underwent PTMC were statistically significant associated with improved echocardiogram parameters as following: increase in mitral valve size (p=0.0058) from 0.89 ± 0.2 cm2 (pre) to 1.4 ± 0.4 cm2 (post); reduction in mean pressure gradient across mitral valve (p=0.0283) from 11.5 ± 4.9 mmHg (pre) to 6.9 ± 3.5 mmHg (post); and reduction (p=0.0019) in elevated pulmonary artery systolic pressure from 65.7 ± 21.4 mmHg (pre) to 45.6 ± 10.0 mmHg (post). More than half (62.5%, n=5) of the subjects with favourable Wilkin score 8 or less achieved good outcome defined as post-PTMC mitral valve size ≥ 1.5 cm2 . All subjects with unfavourable Wilkin score of more than 8 only achieved sub-optimal post-PTMC mitral valve size ≤ 1.5 cm2 . Conclusion: Given the minimally invasive nature of PTMC with comparable excellent haemodynamic outcome to invasive vascular repair, PTMC should be the recommended first line therapy in mitral valve stenosis

Different vascular healing process between bioabsorbable polymer-coated everolimus-eluting stents versus bioresorbable vascular scaffolds via optical coherence tomography and coronary angioscopy (the ENHANCE study: ENdothelial Healing Assessment with Novel Coronary tEchnology)

Recent clinical trials have raised concerns about the safety and efficacy of ABSORB™ bioresorbable vascular scaffolds (BVS). The difference in the vascular healing process between SYNERGY™ bioabsorbable polymer-coated everolimus-eluting stents (BP-EES) and BVS remains unclear. The aim of the ENHANCE study was to compare vascular healing on BP-EES versus BVS by optical coherence tomography (OCT) and coronary angioscopy (CAS) at 4- and 12-month follow-ups. This is a prospective, non-randomized, single center clinical trial. Thirteen eligible patients with multivessel disease were enrolled. BP-EES and BVS were simultaneously implanted in the same patients, but in different coronary vessels. Imaging follow-up with both OCT and CAS was completed in 11 patients at 12 months. Neointimal coverage rates were similar between the two groups based on OCT measurements. The neointimal thickness of BP-EES was significantly thicker at the 12th month than at the 4th month, whereas the neointimal thickness of BVS did not change between the measurements taken at the 4th and 12th month. Existence of intra-stent thrombus was significantly higher in the BVS group, compared to the BP-EES group. On the other hand, CAS revealed that red-thrombi and yellow-plaque were more frequently observed in BVS at 4 months and up to 12-month follow-ups than in BP-EES. These findings suggested that the evidence of instability remained up to 12 months in the vascular healing with BVS, compared to that with BP-EES. Vascular healing of the stented wall was recognized at the very early phase after BP-EES implantation. However, vascular healing with BVS was still incomplete after 12 months. © 2019, The Author(s)

Outcomes of STEMI patients with chronic kidney disease treated with percutaneous coronary intervention: the Malaysian National Cardiovascular Disease Database – Percutaneous Coronary Intervention (NCVD-PCI) registry data from 2007 to 2014

Abstract Background Patients with renal impairment often left out from most major clinical trials assessing the optimal treatment for ST-elevation myocardial infarction (STEMI). Large body of evidence from various cardiovascular registries reflecting more ‘real-world’ experience might contribute to the knowledge on how best to treat this special cohort. We aim to analyze the outcomes of Malaysian STEMI patients with renal impairment treated with coronary angioplasty. Methods Utilizing the Malaysian National Cardiovascular Disease Database-Percutaneous Coronary Intervention (NCVD-PCI) registry data from 2007 to 2014, STEMI patients treated with percutaneous coronary intervention (PCI) were stratified into presence (GFR < 60 mls/min/1.73m2) or absence (GFR ≥ 60 mls/min/1.73m2) of chronic kidney disease (CKD). Patient’s demographics, extent of coronary artery disease, procedural data, discharge medications, short (in-hospital) and long (1 year) term outcomes were critically assessed. Results A total of 6563 patients were included in the final analysis. STEMI CKD cohort was predominantly male (80%) with mean age of 61.02 ± 9.95 years. They had higher cardiovascular risk factors namely diabetes mellitus (54.6%), hypertension (79.2%) and dyslipidemia (68.8%) in contrast to those without CKD. There were notably higher percentage of CKD patients presented with Killip class 3 and 4; 24.9 vs 8.7%. Thrombolytic therapy remained the most commonly instituted treatment regardless the status of kidney function. Furthermore, our STEMI CKD cohort also was more likely to receive less of evidence-based treatment upon discharge. In terms of outcomes, patients with CKD were more likely to develop in-hospital death (OR: 4.55, 95% CI 3.11–6.65), MACE (OR: 3.42, 95% CI 2.39–4.90) and vascular complications (OR: 1.88, 95% CI 0.95–3.7) compared to the non-CKD patients. The risk of death at 1-year post PCI in STEMI CKD patients was also reported to be high (HR: 3.79, 95% CI 2.84–5.07). Conclusion STEMI and CKD is a deadly combination, proven in our cohort, adding on to the current evidence in the literature. We noted that our STEMI CKD patients tend to be younger than the Caucasian with extremely high prevalence of diabetes mellitus. The poor outcome mainly driven by immediate or short term adverse events peri-procedural, therefore suggesting that more efficient treatment in this special group is imperative