Francis J. Ha

Percutaneous Coronary Intervention Using Drug-Eluting Stents Versus Coronary Artery Bypass Grafting for Unprotected Left Main Coronary Artery Stenosis: A Meta-Analysis of Randomized Trials

Background—Current guidelines suggest that coronary artery bypass grafting (CABG) should be the preferred revascularization method for unprotected left main coronary artery stenosis. In light of evidence from recent randomized trials, we assessed whether percutaneous coronary intervention (PCI) using drug-eluting stents is as safe and effective as CABG for the treatment of unprotected left main coronary artery disease. Methods and Results—Digital databases and manual searches were performed for randomized trials comparing PCI and CABG for unprotected left main coronary artery stenosis. Among 3887 potentially relevant studies, 5 met inclusion criteria. The primary safety end point was defined as the composite of all-cause death, myocardial infarction, or stroke. Secondary end points included a clinical effectiveness composite, which was defined as all-cause death, myocardial infarction, stroke, or repeat revascularization. Summary estimates were obtained using random-effects modeling. In total, 4594 patients were included in the analysis. There was no significant difference in the primary safety end point between the revascularization strategies (odds ratio [OR], 0.97; 95% confidence interval [CI], 0.79–1.17; P=0.73). However, when compared with CABG, PCI was less effective (OR, 1.36; 95% CI, 1.18–1.58; P<0.001) because of significantly higher rates of repeat revascularization (OR, 1.85; 95% CI, 1.53–2.23; P<0.001). The incidence of all-cause death (OR, 1.03; 95% CI, 0.78–1.35; P=0.61), myocardial infarction (OR, 1.46; 95% CI, 0.88–2.45; P=0.08), and stroke (OR, 0.88; 95% CI, 0.39–1.97; P=0.53) did not differ between PCI and CABG. Conclusions—PCI using drug-eluting stents and CABG are equally safe methods of revascularization for patients at low surgical risk with significant unprotected left main coronary artery stenosis. However, CABG is associated with significantly lower rates of repeat revascularization.

Crohn's disease: a clinical update.

Crohn’s disease is increasing in prevalence worldwide. It arises from a complex interplay between both genetic predisposition and environmental influence. A search of databases and clinical practice guidelines was performed to provide the most up-to-date evidence-based approach for diagnosing and managing patients with Crohn’s disease. No single gold standard investigation exists. Whilst full ileocolonoscopy with biopsies remains the mainstay for diagnosis, other less invasive imaging modalities are being actively considered in the workup, as well as the use of serological markers. Management should incorporate dietary and lifestyle modifications where necessary, the use of medications in induction and remission of disease, and consideration of surgical intervention where medical therapy has failed.

Midterm Safety and Efficacy of ABSORB Bioresorbable Vascular Scaffold Versus Everolimus-Eluting Metallic Stent: An Updated Meta-Analysis

One of the principal aims in developing bioresorbable vascular scaffolds (BVS) was reduction in the long-term risk of stent-related complications, including very late (>1 year) stent thrombosis (ST). However, recent data suggest that the risk of very late ST may persist, or even be increased, in BVS

Continuous and minimally-interrupted direct oral anticoagulant are both safe compared with vitamin K antagonist for atrial fibrillation ablation: An updated meta-analysis

BACKGROUND The appropriate and safe peri-procedural anticoagulation schedule for patients on a direct oral anticoagulant (DOAC) undergoing AF ablation is not known. We aimed to evaluate the safety and efficacy of both continuous and minimally-interrupted novel oral anticoagulant (DOAC) strategies compared with uninterrupted vitamin K antagonist (VKA) for atrial fibrillation (AF) ablation. METHODS We searched electronic databases for randomized or prospective controlled observational studies comparing DOAC (continuous or interrupted) versus uninterrupted VKA. The primary endpoint was major bleeding. Secondary endpoints were total bleeding (composite of major and minor bleeding) and symptomatic thromboembolism. Data were analyzed by random-effects modeling and sensitivity analyses performed according to study design and peri-procedural DOAC schedule. RESULTS Thirteen studies (4 randomized, 9 observational) with 5463 patients were included in final analysis (45% on DOAC). DOAC was associated with less major bleeding compared with VKA in pooled randomized studies (odds ratio [OR] 0.27, 95% confidence interval [CI] 0.09-0.80, p = 0.03, I2 = 0%), however there was no difference on overall analyses (OR 0.70, 95% CI 0.39-1.24, p = 0.22, I2 = 27%). When stratified by DOAC dose schedule, there was no difference in major bleeding for continuous DOAC (OR 0.48, 95% CI 0.21-1.11, p = 0.09, I2 = 6%) or minimally-interrupted DOAC (OR 0.81, 95% CI 0.37-1.76, p = 0.60, I2 = 43%) compared with VKA. There was no difference between DOAC and VKA for risk of total bleeding (p = 0.20) or symptomatic thromboembolism (p = 0.78). CONCLUSION Continuous and minimally-interrupted DOAC are both safe and non-inferior peri-procedural anticoagulation strategies compared with uninterrupted VKA for AF ablation. DOAC in general is associated with reduced major bleeding as demonstrated in pooled randomized studies.

Quality of Life after Intestinal Resection in Patients with Crohn Disease: A Systematic Review

Background/Aims: Most patients with Crohn disease (CD) require surgery within 10 years of diagnosis. Intestinal resection is the most commonly performed operation although the effects on health-related quality of life (HRQOL), particularly long-term, are contentious. Methods: We conducted a systematic review evaluating the impact of intestinal resection on the HRQOL of CD patients, predictors of postoperative HRQOL, and patient satisfaction with surgery. Results: Nine studies including 1,108 CD patients undergoing intestinal resection were identified as eligible for inclusion. The median age at surgery was 29-41 years with varying follow-up period (range 30 days-5 years). Ileocolic resection was the most commonly performed operation on an elective basis (range 95-100%). HRQOL improved as early as 2 weeks postoperatively and lasted up to 5 years across both generic and gastrointestinal domains. Gender, smoking, and disease recurrence were potential predictors of postoperative HRQOL. Patient satisfaction is high with regard to surgery, with preference for a laparoscopic approach. Conclusion: Intestinal resection in CD patients improved HRQOL in the short- and long-term and patients describe high satisfaction about their surgery. Further studies are needed to validate potential predictors of postoperative HRQOL in this cohort.

Novel Approaches To Undergraduate Oncology Education

With the increasing incidence of cancer and related survival, junior doctors are more commonly involved the management of oncology patients. A comprehensive oncology curriculum has been developed and adopted across medi-cal schools in Australia. However, it was not designed to inform how medical students should be taught, and whether curriculum content translates to knowledge and competency can depend on its implementation. We have conducted a literature review of PubMed, Embase and Cochrane databases to identify and summarise the evidence for novel approaches to delivering the undergraduate oncology curriculum. Numerous effective approaches have been developed across areas of prevention, clinical examination through simulation, the multidisciplinary team, psycho-oncology, palliative care and even research. There is growing focus on a holistic and multidisciplinary approach to cancer education although direct clinical exposure and interactions with cancer patients is still crucial. Medical schools may also have an under-recognised role in promoting positive health behaviour if their graduates are to convey these preventative measures to their patients. Application of such methods relies upon clinicians and medical educators to consider the practicability and relevance of specific implementation in their local context.

Heart Failure and Exercise: A Narrative Review of the Role of Self-Efficacy

Chronic heart failure (CHF) is a common, debilitating condition associated with significant health and economic burden. CHF management is multidisciplinary, however, achieving better health relies on a collaborative effort and patient engagement in self-care. Despite the importance of self-care in CHF, many patients have poor adherence to their medical and lifestyle regimens, in particular with regards to engaging in physical exercise. The patients confidence in their ability, otherwise known as self-efficacy, is an important determinant of CHF health outcomes, most likely due to its effect on the uptake of CHF self-care activities especially exercise initiation and maintenance. Self-efficacy is responsive to experience such as exercise training, however the critical components of exercise interventions to improve self-efficacy have yet to be determined. This narrative review provides an overview of the role of self-efficacy in exercise adherence in CHF.

Association between the 6-minute walk test and exercise confidence in patients with heart failure: A prospective observational study

Background: Exercise confidence predicts exercise adherence in heart failure (HF) patients. The association between simple tests of functional capacity on exercise confidence are not known. Objectives: To evaluate the association between a single 6‐min walk test (6MWT) and exercise confidence in HF patients. Methods: Observational study enrolling HF outpatients who completed the Cardiac Depression Scale and an Exercise Confidence Survey at baseline and following the 6MWT. Paired t‐test was used to compare repeated‐measures data, while Repeated Measures Analysis of Covariance was used for multivariate analysis. Results: 106 HF patients were enrolled in the study (males, 82%; mean age, 64 ± 12 years). Baseline Exercise Confidence was inversely associated with age (p < 0.01), NYHA class (p < 0.001), and depression (p < 0.001). The 6MWT was associated with an improvement in Exercise Confidence (F(1,92) = 5.0, p = 0.03) after adjustment for age, gender, HF duration, NYHA class and depression. Conclusions: The 6MWT is associated with improved exercise confidence in HF patients.

Computed Tomographic Coronary Angiography–Derived Plaque Characteristics Predict Major Adverse Cardiovascular EventsCLINICAL PERSPECTIVE: A Systematic Review and Meta-Analysis

Background— Computed tomographic coronary angiography is a noninvasive imaging modality that permits identification and characterization of coronary plaques. Despite consensus statements supporting routine reporting of computed tomographic coronary angiography plaque characteristics, there remains uncertainty whether these data convey prognostic information. We performed a systematic review and meta-analysis assessing the strength of association between computed tomographic coronary angiography–derived plaque characterization and major adverse cardiovascular events (MACE). Methods and Results— Electronic databases were searched for studies reporting computed tomographic coronary angiography plaque characterization and MACE. Data were gathered on plaque morphology (noncalcified, partially calcified, and calcified) and high-risk plaque (HRP) features, including low-attenuation plaque, napkin-ring sign, spotty calcification, and positive remodeling. Of 5496 citations, 13 studies met inclusion criteria. Five hundred fifty-two (3.9%) MACE occurred in 13 977 patients with mean follow-up ranging between 1.3 and 8.2 years. In terms of plaque morphology, the strongest association was observed for noncalcified plaque (hazard ratio [HR], 1.45; 95% confidence interval [CI], 1.24–1.70; P<0.001), with weaker associations found for partially calcified (HR, 1.37; 95% CI, 1.18–1.60; P<0.001) and calcified plaques (HR, 1.23; 95% CI, 1.16–1.30; P<0.001). All HRP features were strongly associated with MACE, including napkin-ring sign (HR, 5.06; 95% CI, 3.23–7.94; P<0.001), low-attenuation plaque (HR, 2.95; 95% CI, 2.03–4.29; P<0.001), positive remodeling (HR, 2.58; 95% CI, 1.84–3.61; P<0.001), and spotty calcification (HR, 2.25; 95% CI, 1.26–4.04; P=0.006). The presence of ≥2 HRP features had highest risk of MACE (HR, 9.17; 95% CI, 4.10–20.50; P<0.001). Conclusions— These data demonstrate that HRP is most likely an independent predictor of MACE, which supports the inclusion of HRP reporting in clinical practice. However, at this point, it remains unclear whether HRP reporting has clinical implications.

Optical Coherence Tomography Guided Percutaneous Coronary Intervention

Optical coherence tomography (OCT) is an increasingly available intracoronary imaging modality that provides high-resolution imaging of coronary arteries. Its fundamental reliance on the emission and reflection of light enables rapid data acquisition without compromise of image resolution. As such, OCT can inform operators planning percutaneous coronary intervention (PCI) by accurately defining luminal geometry and detailing plaque composition. Following PCI, OCT imaging delivers a thorough assessment of the treated arterial segment and can identify specific features not always visible on alternate imaging modalities, including stent edge-related dissection, plaque tissue prolapse, incomplete stent apposition and the presence of intra-coronary thrombus. Clinical trials highlight that procedural strategy is frequently altered based on OCT findings, while concerns over final stent dimensions have been mitigated through use of a sizing protocol based on external elastic lamina dimensions in the reference arterial segment. Randomised trials are now warranted to definitively ascertain whether OCT-guidance improves clinical outcomes when utilised during PCI.