Meta-analysis of death and myocardial infarction in the DEFINE-FLAIR and iFR-SWEDEHEART trials: a hypothesis generating note of caution

In patients with coronary heart disease, revascularization can improve symptoms and in certain high-risk subgroups may improve prognosis. Coronary angiography provides anatomical information and the physiological significance of a stenosis can be determined using fractional flow reserve (FFR). Decisions on the need for and mode of revascularization can be optimized using FFR, however this involves administering adenosine to induce hyperemia. Generally, this test is well tolerated, but in some healthcare systems adenosine is either not licensed, unavailable, or expensive, limiting the use of FFR-guided management

“Waves of Edema” seem implausible

No abstract available

Radial versus femoral access for rotational atherectomy: A UK observational study of 8622 patients

Background—Rotational atherectomy (RA) is an important interventional tool for heavily calcified coronary lesions. We compared the early clinical outcomes in patients undergoing RA using radial or femoral access. Methods and Results—We identified all patients in England and Wales who underwent RA between January 1, 2005, and March 31, 2014. Eight thousand six hundred twenty-two RA cases (3069 radial and 5553 femoral) were included in the analysis. The study primary outcome was 30-day mortality. Propensity scores were calculated to determine the factors associated with treatment assignment to radial or femoral access. Multivariable logistic regression analysis, using the calculated propensity scores, was performed. Thirty-day mortality was 2.2% in the radial and 2.3% in the femoral group (P=0.76). Radial access was associated with equivalent 30-day mortality (adjusted odds ratio [OR], 1.06; 95% confidence interval [CI], 0.77–1.46; P=0.71), procedural success (OR, 1.04; 95% CI, 0.84–1.29; P=0.73), major adverse cardiac and cerebrovascular events (OR, 1.05; 95% CI, 0.80–1.38; P=0.72), and net adverse clinical events (OR, 0.90; 95% CI, 0.71–1.15; P=0.41), but lower rates of in-hospital major bleeding (OR, 0.62; 95% CI, 0.40–0.98; P=0.04) and major access site complications (OR, 0.05; 95% CI, 0.01–0.38; P=0.004), compared with femoral access. Conclusions—In this large real-world study of patients undergoing RA, radial access was associated with equivalent 30-day mortality and procedural success, but reduced major bleeding and access site complications, compared with femoral access

Simulating Drug-Eluting Stents: Progress Made and the Way Forward

Drug-eluting stents have significantly improved the treatment of coronary artery disease. Compared with their bare metal predecessors, they offer reduced rates of restenosis and thus represent the current gold standard in percutaneous coronary interventions. Drug-eluting stents have been around for over a decade, and while progress is continually being made, they are not suitable in all patients and lesion types. Furthermore there are still real concerns over incomplete healing and late stent thrombosis. In this paper, some modelling approaches are reviewed and the future of modelling and simulation in this field is discussed

Fractional flow reserve-guided management in stable coronary disease and acute myocardial infarction: recent developments

Coronary artery disease (CAD) is a leading global cause of morbidity and mortality, and improvements in the diagnosis and treatment of CAD can reduce the health and economic burden of this condition. Fractional flow reserve (FFR) is an evidence-based diagnostic test of the physiological significance of a coronary artery stenosis. Fractional flow reserve is a pressure-derived index of the maximal achievable myocardial blood flow in the presence of an epicardial coronary stenosis as a ratio to maximum achievable flow if that artery were normal. When compared with standard angiography-guided management, FFR disclosure is impactful on the decision for revascularization and clinical outcomes. In this article, we review recent developments with FFR in patients with stable CAD and recent myocardial infarction. Specifically, we review novel developments in our understanding of CAD pathophysiology, diagnostic applications, prognostic studies, clinical trials, and clinical guidelines

Arterial access for invasive coronary angiography: the 'left backhander'

No abstract available

The relationship between oxidised LDL, endothelial progenitor cells and coronary endothelial function in patients with CHD

Objective The balance between coronary endothelial dysfunction and repair is influenced by many protective and deleterious factors circulating in the blood. We studied the relationship between oxidised low-density lipoprotein (oxLDL), circulating endothelial progenitor cells (EPCs) and coronary endothelial function in patients with stable coronary heart disease (CHD). Methods 33 patients with stable CHD were studied. Plasma oxLDL was measured using ELISA, coronary endothelial function was assessed using intracoronary acetylcholine infusion and EPCs were quantified using flow cytometry for CD34+/KDR+ cells. Results Plasma oxLDL correlated positively with the number of EPCs in the blood (r=0.46, p=0.02). There was a positive correlation between the number of circulating EPCs and coronary endothelial function (r=0.42, p=0.04). There was no significant correlation between oxLDL and coronary endothelial function. Conclusions Plasma levels of oxLDL are associated with increased circulating EPCs in the blood of patients with CHD, which may reflect a host-repair response to endothelial injury. Patients with stable CHD had a high prevalence of coronary endothelial dysfunction, which was associated with lower numbers of circulating EPCs, suggesting a mechanistic link between endothelial dysfunction and the pathogenesis of atherosclerosis

Single versus two-stent strategies for coronary bifurcation lesions: a systematic review and meta-analysis of randomized trials with long-term follow-up

Background: The majority of coronary bifurcation lesions are treated with a provisional single‐stent strategy rather than an up‐front 2‐stent strategy. This approach is supported by multiple randomized controlled clinical trials with short‐ to medium‐term follow‐up; however, long‐term follow‐up data is evolving from many data sets. Methods and Results: Meta‐analysis of randomized controlled trials evaluating long‐term outcomes (≥1 year) according to treatment strategy for coronary bifurcation lesions. Nine randomized controlled trials with 3265 patients reported long‐term clinical outcomes at mean weighted follow‐up of 3.1±1.8 years. Provisional single stenting was associated with lower all‐cause mortality (2.94% versus 4.23%; risk ratio: 0.69; 95% confidence interval, 0.48–1.00; P=0.049; I2=0). There was no difference in major adverse cardiac events (15.8% versus 15.4%; P=0.79), myocardial infarction (4.8% versus 5.5%; P=0.51), target lesion revascularization (9.3% versus 7.6%; P=0.19), or stent thrombosis (1.8% versus 1.6%; P=0.28) between the groups. Prespecified sensitivity analysis of long‐term mortality at a mean of 4.7 years of follow‐up showed that the provisional single‐stent strategy was associated with reduced all‐cause mortality (3.9% versus 6.2%; risk ratio: 0.63; 95% confidence interval, 0.42–0.97; P=0.036; I2=0). Conclusions: Coronary bifurcation percutaneous coronary intervention using a provisional single‐stent strategy is associated with a reduction in all‐cause mortality at long‐term follow‐up

Left ventricular outcomes following multivessel PCI vs. infarct artery-only PCI in patients with acute STEMI: the Glasgow PRAMI CMR sub-study

No abstract available