Grant W. Reed

Point-of-care platelet function testing predicts bleeding in patients exposed to clopidogrel undergoing coronary artery bypass grafting: Verify pre-op TIMI 45--a pilot study.

Guidelines recommend delaying coronary artery bypass grafting (CABG) for 5 days after discontinuing clopidogrel. However, platelet function may recover quicker in certain individuals.

Hospital Readmissions Following Endovascular Therapy for Critical Limb Ischemia: Associations With Wound Healing, Major Adverse Limb Events, and Mortality

Background The significance of hospital readmission after endovascular therapy for critical limb ischemia (CLI) is not well established. We sought to investigate the incidence, timing, and causes of readmissions after endovascular therapy for CLI and whether readmission is associated with major adverse limb events (MALE) or mortality. Methods and Results This was a retrospective study of 252 patients treated with endovascular therapy for CLI. During median follow‐up of 381 days (interquartile range [IQR], 115–718), 140 (56%) were readmitted, with median time to readmission of 83 days (IQR, 33–190). Readmission within 30 days occurred in 14% of patients (n=35; 25% of readmissions). Most readmissions occurred between 30 and 180 days (n=67; 48% of readmissions). The most frequent reason for readmission was unhealed wounds (n=63; 45% of readmissions). Independent predictors of readmission by Cox proportional hazards analysis were unhealed wounds, presence of multiple wounds, age ≥70, female sex, hemodialysis, and history of heart failure (P<0.05 for each). By Kaplan–Meier analysis, readmission was greatest in patients with unhealed wounds, followed by patients who never had a wound, and lowest in patients whose wounds completely healed (P<0.0001 overall, and P<0.01 between groups). After multivariable adjustment, readmission remained an independent predictor of composite MALE (major amputation, bypass, or endarterectomy) or mortality (adjusted hazard ratio, 3.1; 95% CI, 1.5–6.5; P=0.002). Conclusions Most readmissions occur 30 and 180 days after endovascular therapy for nonprocedural reasons. Unhealed wounds are an independent risk factor for readmission. Readmission is associated with increased MALE and mortality after endovascular therapy for CLI.

Personalized Approach to Revascularization of Critical Limb Ischemia

Critical limb ischemia (CLI) is a complex disease process that often occurs alongside numerous comorbidities, and as such requires a personalized, multidisciplinary treatment approach in every patient. Patient outcomes are generally poor and there remains a lack of consensus on the optimal revascularization strategy in individuals with CLI. In recent years, the angiosome (or direct) revascularization concept has gained wider acceptance because it guides reperfusion to the artery supplying the vascular territory containing the ischemic lesion on the foot (Figure).1,2 However, it stands in contrast to the one straight-line inflow (or indirect) approach classically advocated, in which the largest vessel available for revascularization is targeted regardless of the vascular territory it supplies.3 Comparisons between both strategies have emerged, with few studies demonstrating equivalent outcomes and many others demonstrating improved wound healing and reduced amputation rates with the angiosome approach.4,5 Figure. Angiosomes of the lower extremity. The foot and ankle can be divided into 6 territories called angiosomes, based on the artery supplying the given territories. This concept can aid in localizing the obstruction in a specific artery in patients with critical limb ischemia and lower-extremity ischemic ulcers and in planning revascularization. Reprinted from Shishehbor et al1 with permission of the publisher. Copyright ©2014, The Cleveland Clinic Foundation. All rights reserved. Article see p 684 The current study by Kawarada et al6 in this issue of Circulation: Cardiovascular Interventions is important, as it is one of the first analyses to address the impact of the angiosome concept on microcirculation in patients with CLI. However, there are a few limitations of the current study that should be considered and discussed. The authors concluded that both direct and indirect single tibial artery revascularization of either the anterior tibial artery or posterior tibial artery …

The Effect of Post-Exercise Ankle-Brachial Index on Lower Extremity Revascularization.

OBJECTIVES The purpose of this study was to investigate the effect of post-exercise ankle-brachial index (ABI) on the incidence of lower extremity (LE) revascularization, cardiovascular outcomes, and all-cause mortality in patients with normal and abnormal resting ABI. BACKGROUND The clinical and prognostic value of post-exercise ABI in the setting of normal or abnormal resting ABI remains uncertain. METHODS A total of 2,791 consecutive patients with ABI testing between September 2005 and January 2010 were classified into group 1: normal resting (NR)/normal post-exercise (NE); group 2: NR/abnormal post-exercise (AE); group 3: abnormal resting (AR)/NE; and group 4: AR/AE. Abnormal post-exercise ABI was defined as a drop of >20% from resting ABI as per the American College of Cardiology/American Heart Association guidelines. The primary endpoint was incidence of LE revascularization. Secondary endpoints were major adverse cardiovascular events (MACE) and all-cause mortality. Associations between post-exercise ABI and outcomes were adjusted using multivariable Cox proportional hazard and propensity analyses. RESULTS Compared with group 1 (NR/NE), group 2 (NR/AE) had increased LE revascularization (propensity-matched adjusted hazard ratio [HR]: 6.63, 95% confidence interval [CI]: 3.13 to 14.04; p < 0.001) but no differences in MACE or all-cause mortality. When resting ABI was abnormal, group 4 (AR/AE) compared with group 3 (AR/NE), abnormal post-exercise ABI was still associated with increased LE revascularization (adjusted HR: 1.59, 95% CI: 1.11 to 2.28; p = 0.01), which persisted after propensity matching (adjusted HR: 2.32, 95% CI: 1.52 to 3.54; p < 0.001). Compared with group 1 (NR/NE) and after propensity matching, group 4 (AR/AE) had a significant increase in MACE (adjusted HR: 1.44, 95% CI: 1.09 to 1.90; p = 0.009) and a trend toward increased all-cause mortality (adjusted HR: 1.37, 95% CI: 0.99 to 1.88; p = 0.052); however, group 3 (AR/NE) did not. CONCLUSIONS Post-exercise ABI appears to offer both clinical (lower extremity revascularization) and prognostic information in those with normal and abnormal resting ABI.

Triple Oral Antithrombotic Therapy in Atrial Fibrillation and Coronary Artery Stenting

Patients with atrial fibrillation affected by an acute coronary syndrome have indications for oral anticoagulation and dual antiplatelet therapy with aspirin and a P2Y12 adenosine diphosphate receptor inhibitor after coronary artery stenting. The concurrent use of all 3 agents, termed triple oral antithrombotic therapy, significantly increases the risk of bleeding. To date, there is a lack of evidence on the proper combination and duration of anticoagulant and antiplatelet agents in patients with indications for both therapies. As such, care has been guided by expert opinion, and there is wide variation in clinician practice. In this review, the latest evidence on the risks and benefits of triple oral antithrombotic therapy in patients with atrial fibrillation after coronary artery stenting is summarized. We discuss the clinical risk scores useful in guiding the prediction of stroke, bleeding, and stent thrombosis. Additionally, we highlight where additional evidence is needed to determine the proper balance of anticoagulant and antiplatelet agents in this patient population.

Long-Term Mortality in Patients With Radiation-Associated Coronary Artery Disease Treated With Percutaneous Coronary Intervention

Background—The incidence and predictors of long-term mortality after percutaneous coronary intervention (PCI) for radiation-associated coronary artery disease are unknown. Methods and Results—In this observational study of 314 patients (age, 65.2±11.4 years; 233 [74%] women) treated with PCI, 157 patients with previous external beam radiation therapy (XRT) were matched 1:1 with 157 comparison patients with atherosclerotic coronary artery disease without previous XRT, based on age, sex, lesion artery, and PCI type. The primary end point was all-cause mortality, and the secondary end point was cardiovascular mortality. After follow-up of 6.6±5.5 years, there were 101 deaths; 59 in the XRT group and 42 in the comparison group (P=0.04). On Cox proportional hazards multivariable survival analysis, previous XRT remained an independent predictor of all-cause mortality (hazard ratio [HR] 1.85; 95% confidence interval [CI], 1.21–2.85; P=0.004) and cardiovascular mortality (HR, 1.70; 95% CI, 1.06–2.89; P=0.03). Additional independent predictors of increased all-cause mortality included balloon angioplasty or bare-metal stent placement compared with drug-eluting stent placement (HR, 2.50; 95% CI, 1.61–3.97; P<0.0001), SYNTAX (Synergy Between PCI With Taxus and Cardiac Surgery) score of ≥11 (the sample median; HR, 1.99; 95% CI, 1.32–3.04; P<0.001), New York Heart Association functional class ≥3 (HR, 1.83; 95% CI, 1.15–2.91; P=0.012), history of smoking (HR, 1.88; 95% CI, 1.10–3.09; P=0.022), and age ≥65 years (HR, 1.70; 95% CI, 1.07–2.07; P=0.024). Conclusions—Compared with patients with typical atherosclerotic coronary artery disease, patients with radiation-associated coronary artery disease are at higher risk for mortality after PCI. Previous XRT exposure is independently associated with increased all-cause and cardiovascular mortality in patients treated with PCI.

Troponin elevation after colorectal surgery: Significance and management

Objective: The aim of this study is to identify the association between early postoperative troponin elevations and outcomes after major colorectal surgery. Background: Myocardial infarction is the leading cause of death after noncardiac surgery. Most postoperative myocardial infarctions are clinically silent, and asymptomatic troponin elevations have the same early mortality as symptomatic infarctions. Methods: Patients over the age of 45, undergoing major colorectal surgery from March 2015 to January 2016, were identified. Plasma troponin T concentrations were prospectively collected within 24 and 48 hours after surgery. Characteristics, evaluations, management, and outcomes of patients with elevated troponin concentrations were analyzed. Mortality within the follow-up period was the primary end point. Results: A total of 1020 patients were screened with postoperative troponin concentrations. Fifty patients had troponin concentrations >0.01 ng/mL. Patients rarely (16%) had ischemic symptoms. Cardiology was consulted for 23 patients and started on medical therapy. Seventeen of these patients were alive at follow-up. Ten patients (20%) with troponin concentrations >0.01 ng/mL died within the follow-up period, 7 of which had concentrations ≥0.03 ng/mL. Conclusions: Most postoperative myocardial injury is asymptomatic and may only be detected by routine troponin screening. Elevated troponin concentrations after colorectal surgery may facilitate identifying patients at postoperative risk and prompt appropriate testing. Early intervention in select patients may lead to potential reduction of mortality after major colorectal surgery.

Catheter-based closure of paravalvular leak

Paravalvular leak (PVL) is a serious complication from surgical and percutaneous valve replacement procedures. The most common manifestations include congestive heart failure and hemolytic anemia, which may cause considerable morbidity and mortality. Repeat surgery for PVL closure is often complicated and carries a reduced probability of success. As such, catheter-based techniques to eliminate PVL have been developed. Percutaneous PVL closure procedures rely heavily on multimodality imaging techniques such as echocardiography, fluoroscopy and computed tomography for diagnosis, technical planning and procedural guidance. Evidence demonstrates that catheter-based closure of PVL boasts high procedural success rates and favorable clinical outcomes. Given the rapidly advancing nature of this field, this review summarizes the contemporary diagnosis of PVL, common techniques used for percutaneous closure and the latest data on patient outcomes following this procedure.

Influence of smoking on the antiplatelet effect of clopidogrel differs according to clopidogrel dose: Insights from the GRAVITAS trial

To examine the influence of smoking on the antiplatelet effect of clopidogrel following percutaneous coronary intervention (PCI).

Prevalence of Tibial Artery and Pedal Arch Patency by Angiography in Patients With Critical Limb Ischemia and Noncompressible Ankle Brachial Index

Background— Approximately 20% of patients undergoing ankle brachial index testing for critical limb ischemia have noncompressible vessels because of tibial artery calcification. This represents a clinical challenge in determining tibial artery patency. We sought to identify the prevalence of tibial artery and pedal arch patency by angiography in these patients. Methods and Results— One hundred twenty-five limbs (of 89 patients) with critical limb ischemia and ankle brachial index ≥1.4 who underwent lower extremity angiograms within 1 year were included. Reviewers of angiography were blinded to results of physiological testing. Tibial artery vessels were classified as completely occluded, significantly stenosed (≥50%), or patent (<50% stenosis). The sensitivity of toe brachial index and pulse volume recording to predict tibial artery disease was also determined. Of 125 limbs with noncompressible ankle brachial index, 72 (57.6%) anterior tibial and 80 (64%) posterior tibial arteries were occluded. Another 23 (18.4%) anterior tibial and 13 (10.4%) posterior tibial arteries had ≥50% stenosis. Pulse volume recording was moderate to severely dampened in 54 of 119 (45.4%) limbs. Toe brachial index <0.7 was found in 75 of 83 (90.4%) limbs. Moderate to severe pulse volume recording dampening was 43.6% sensitive, whereas toe brachial index <0.7 was 89.7% sensitive in diagnosing occluded or significantly stenotic tibial artery disease. The pedal arch was absent or incomplete in 86 of 103 (83.5%) limbs. Conclusions— Among patients with critical limb ischemia and noncompressible ankle brachial index results, the prevalence of occlusive tibial and pedal arch disease is very high. Toe brachial index <0.7 is more sensitive in diagnosing occluded and significantly stenotic tibial artery disease in these patients compared with ankle pulse volume recording.