Jiqiang He

Impact of diabetes mellitus on patients with unprotected left main coronary artery lesion disease treated with either percutaneous coronary intervention or coronary-artery bypass grafting.

ObjectiveThis study was conducted to evaluate the impact of diabetes on patients with unprotected left main coronary artery (LMCA) disease treated with either percutaneous coronary intervention (PCI) or coronary-artery bypass grafting (CABG). BackgroundThe optimal coronary revascularization strategy in diabetic patients with unprotected LMCA disease remains uncertain. MethodsA total of 823 consecutive patients having unprotected LMCA disease, who received drug-eluting stent (DES) (n=331) implantation or underwent CABG (n=492), were retrospectively analyzed. We compared the effects of these two treatments on clinical outcomes [death, cardiac death, myocardial infarction (MI), stroke, target vessel revascularization, and the composite of death, MI, or stroke], according to the patients’ diabetic status. ResultsAfter multivariable adjustment, the risk of death [hazard ratio (HR): 1.096, 95% confidence interval (CI): 0.541–2.222; P=0.799] and that of the composite of death, MI, or stroke (HR: 0.769, 95% CI: 0.446–1.328; P=0.346) were similar in the DES and CABG groups. However, the rate of target vessel revascularization was significantly higher in the DES group (HR: 0.169, 95% CI: 0.079–0.358; P<0.001). Incidence of MI (HR: 1.314, 95% CI: 0.238–7.254; P=0.754) and that of the composite of death, MI, or stroke (HR: 1.497, 95% CI: 0.682–3.289; P=0.315) were similar between DES and CABG in the nondiabetic group; however, in the diabetic population incidence of the composite of death, MI, or stroke (HR: 0.31, 95% CI: 0.126–0.761; P=0.011) was significantly higher in the DES compared with the CABG group, driven mainly by the significantly higher rate of MI in the DES group (HR: 0.114, 95% CI: 0.022–0.593; P=0.01). Rate of repeat revascularization was higher with DES compared with CABG in both diabetic and nondiabetic groups. ConclusionThere was a prognostic impact of diabetes mellitus on treatment effects in patients with unprotected LMCA lesions who underwent DES or CABG. For patients with unprotected LMCA lesions, PCI with DES was an acceptable alternative to CABG at risk for higher repeat revascularization in the nondiabetic cohort, whereas in the diabetic cohort PCI with DES was inferior to CABG in terms of both safety and efficacy.

Duration of dual antiplatelet therapy after implantation of the first-generation and second-generation drug-eluting stents.

ObjectiveThis study was carried out to determine the effect of the use of dual antiplatelet therapy (DAPT) for more than 12 months on long-term clinical outcomes in patients who had undergone a percutaneous coronary intervention with the first and second generations of drug-eluting stents (DES). BackgroundThe potential benefits of the use of DAPT beyond a 12-month period in patients receiving DES have not been established clearly. Moreover, it is also unclear whether the optimal duration of DAPT is similar for all DES types. MethodsA total of 2141 patients with coronary artery disease treated exclusively with Cypher sirolimus-eluting stents (SES) or Endeavor zotarolimus-eluting stents (ZES) were considered for retrospective analysis. The primary endpoint [a composite of all-cause mortality, nonfatal myocardial infarction (MI), and stroke] was compared between the 12-month DAPT and the >12-month DAPT group. ResultsA total of 1870 event-free patients on DAPT at 12 months were identified. The average follow-up was 28.2±7.4 months. The primary outcomes were similar between the two groups (4.1% 12-month DAPT vs. 1.9% >12-month DAPT; P=0.090). Incidences of death, MI, stroke, and target vessel revascularization did not differ significantly between the two groups. Subgroup analysis showed that in the patients with hypertension, >12-month DAPT significantly reduced the occurrence of death/MI/stroke compared with that in the 12-month DAPT group (P=0.04). In patients implanted with SES, the primary outcome was significantly lower with the >12-month DAPT group (5.2% 12-month DAPT vs. 1.6% >12-month DAPT; P=0.016), whereas in patients with ZES, the primary outcome was comparable between the two groups (2.3% 12-month DAPT vs. 2.0% >12-month DAPT; P=0.99). ConclusionIn our study, for all patients, >12-month DAPT in patients who had received DES was not significantly more effective than 12-month DAPT in reducing the rate of death/MI/stroke. Our findings, that patients who received SES benefit from >12-month DAPT whereas extended use of DAPT was not significantly more effective in those implanted with ZES, implied that the optimal duration of DAPT was different depending on different types of DES.

Very Long-term Outcomes and Predictors of Percutaneous Coronary Intervention with Drug-eluting Stents Versus Coronary Artery Bypass Grafting for Patients with Unprotected Left Main Coronary Artery Disease

Background:There are limited data on longer-term outcomes (>5 years) for patients with unprotected left main coronary artery (ULMCA) disease who underwent percutaneous coronary intervention (PCI) in the drug-eluting stents (DES) era. This study aimed at comparing the long-term (>5 years) outcomes of patients with ULMCA disease underwent PCI with DES and coronary artery bypass grafting (CABG) and the predictors of adverse events. Methods:All consecutive patients with ULMCA disease treated with DES implantation versus CABG in our center, between January 2003 and July 2009, were screened for analyzing. A propensity score analysis was carried out to adjust for potential confounding between the two groups. Results:Nine hundred and twenty-two patients with ULMCA disease were enrolled for the analyses (DES = 465 vs. CABG = 457). During the median follow-up of 7.1 years (interquartile range 5.3–8.2 years), no difference was found between PCI and CABG in the occurrence of death (P = 0.282) and the composite endpoint of cardiac death, myocardial infarction (MI) and stroke (P = 0.294). Rates of major adverse cardiac and cerebrovascular events were significantly higher in the PCI group (P = 0.014) in large part because of the significantly higher rate of repeat revascularization (P < 0.001). PCI was correlated with the lower occurrence of stroke (P = 0.004). Multivariate analysis showed ejection fraction (EF) (P = 0.012), creatinine (P = 0.016), and prior stroke (P = 0.031) were independent predictors of the composite endpoint of cardiac death, MI, and stroke in the DES group, while age (P = 0.026) and EF (P = 0.002) were independent predictors in the CABG group. Conclusions:During a median follow-up of 7.1 years, there was no difference in the rate of death between PCI with DES implantation and CABG in ULMCA lesions in the patient cohort. CABG group was observed to have significantly lower rates of repeat revascularization but higher stroke rates compared with PCI. EF, creatinine, and prior stroke were independent predictors of the composite endpoint of cardiac death, MI, and stroke in the DES group, while age and EF were independent predictors in the CABG group.

SYNTAX Score-II Predicts Long-Term Mortality in Patients Who Underwent Left Main Percutaneous Coronary Intervention Treated With Second-Generation Drug-Eluting Stents

The aim of this study was to evaluate the capacity of the SYNTAX Score-II (SS-II) to predict long-term mortality in patients undergoing left main percutaneous coronary intervention (LM-PCI) treated with second-generation drug-eluting stents (DES).Data from 487 consecutive patients with de novo left main coronary artery disease undergoing PCI were retrospectively studied. The patients were divided into tertiles according to the SS-II: low SS-II tertile (SS-II ≤ 22), intermediate SS-II tertile (SS-II of 23 to 30), and high SS-II tertile (SS-II ≥ 30). The survival curves were estimated by the Kaplan-Meier method. Univariate and multivariate Cox proportional hazard regression analyses were performed to evaluate the possible associations between the SS-II and the rates of long-term mortality. The predictive ability of the SS-II for mortality was assessed and compared with the SYNTAX score (SS) alone by an area under the receiver operator curve (AUC).The overall SS-II was 27.3 ± 9.1. At a mean follow-up of 5.1 years, the long-term mortality was 6.0%. The rates of mortality were 2.4%, 3.4%, and 11.6%, respectively (P < 0.0001) in the low, intermediate, and high SS-II tertiles. The cardiac mortality rates were 1.8%, 1.4%, and 8.1%, respectively (P = 0.002) among patients in the 3 groups. By multivariate analysis, SS-II was an independent predictor of the long-term mortality (hazard ratio: 1.56, 95% confidence interval: 1.05 to 2.32; P = 0.03). The AUC demonstrated a substantially higher predictive accuracy of the SS-II for mortality compared with the SS alone (AUC was 0.689 and 0.596, respectively).In patients with LM-PCI treated with a second-generation DES, the SS-II is an independent predictor of long-term mortality and demonstrates a superior predictability compared with the SS alone.

Impact of chronic kidney disease on patients with unprotected left main coronary artery disease treated with coronary artery bypass grafting or drug-eluting stents.

ObjectivesThis study aimed to evaluate clinical outcomes after percutaneous coronary intervention with drug-eluting stents (DESs) or coronary artery bypass grafting (CABG) in unprotected left main coronary artery (ULMCA) disease patients with and without chronic kidney disease. BackgroundThe optimal coronary revascularization strategy for ULMCA disease patients with chronic kidney disease remains uncertain. MethodsThe sample included 818 ULMCA disease patients who received DESs (n=358) or underwent CABG (n=460). We retrospectively compared clinical parameters and outcomes between different endogenous creatinine clearance rates [estimated glomerular filtration rates (eGFRs), ml/min×1.73 m2]. ResultsThe incidences of major adverse cardiocerebral events, all-cause death, cardiac death, and stroke were not significantly different between the DES and the CABG groups. The DES group had significantly higher risks of myocardial infarction (MI) and target vessel revascularization than the CABG group. Compared with the CABG group, the hazard ratios for target vessel revascularization were 3.965 [95% confidence interval (CI): 1.743–9.023, P=0.001] in the eGFR of at least 60 group and 46.463 (95% CI: 4.558–473.639, P=0.001) in the eGFR 45–59 group. The rate of MI was higher in patients treated with DESs in the eGFR of less than 45 group (hazard ratio: 14.098, 95% CI: 1.123–176.988, P=0.040). ConclusionFor patients with ULMCA disease at risk of higher repeat revascularization with normal renal function or eGFR of at least 45 ml/min×1.73 m2, DESs are a safe alternative to CABG. However, for patients with severely reduced kidney function (eGFR<45 ml/min×1.73 m2), DESs should be selected after careful evaluation of MI risk.

Influence of Diabetes Mellitus on Long-Term Outcomes of Patients With Unprotected Left Main Coronary Artery Disease Treated With Either Drug-Eluting Stents or Coronary Artery Bypass Grafting

Whether the effect of diabetes on patients with unprotected left main coronary artery (ULMCA) disease differs according to different strategies of revascularization was unknown. This study was conducted to evaluate the impact of diabetes on patients with ULMCA disease treated with either percutaneous coronary intervention (PCI) or coronary-artery bypass grafting (CABG).A total of 922 patients with ULMCA disease who received drug-eluting stent (DES) (n = 465) implantation or underwent CABG (n = 457) were retrospectively analyzed. We compared the effects of these 2 treatments on clinical outcomes (death, myocardial infarction, stroke, repeat revascularization, and the composite of death, myocardial infarction, or stroke), according to diabetic status.During the median follow-up of 7.1 years (interquartile range, 5.3 to 8.2 years), no difference was found between PCI and CABG in the adjusted occurrence of death (P = 0.112) and the composite endpoints of death, myocardial infarction, and stroke (P = 0.235). Significantly higher incidence of repeat revascularization (P < 0.001) was observed in the DES group, whereas the CABG group had a significantly higher rate of stroke (P = 0.001). These trends were consistent in both diabetic and nondiabetic patients. We did not observe significant interactions between treatment outcomes and the presence or absence of diabetes after adjustment for covariates (P(interaction) = 0.580 for the composite of death, MI and stroke, P(interaction) = 0.685 for death, P(interaction) = 0.416 for MI, P(interaction) = 0.470 for stroke, and P(interaction) = 0.502 for repeat revascularization).Presence of diabetes was not important for decision-making between CABG and PCI in patients with ULMCA disease.

The relationship between revascularization extent and the long-term prognosis of patients with stable angina pectoris and three-vessel disease treated by percutaneous coronary intervention in the era of drug-eluting stents.

The effects of revascularization extent (RE) on the long‐term prognosis of patients with stable angina pectoris and 3‐vessel disease who underwent percutaneous coronary intervention were unknown.

Impact of mean platelet aggregation degree on long-term clinical outcomes among patients undergoing a complex percutaneous coronary intervention.

Objective The aim of this study was to evaluate the association between the mean platelet aggregation degree and long-term clinical outcomes in patients receiving a complex percutaneous coronary intervention (CPCI). Patients and methods We screened 2141 patients after a percutaneous coronary intervention (PCI) treated with aspirin and clopidogrel. CPCI was defined as a procedure targeted to at least one of the following: left main disease, bifurcation lesion, ostial lesion, chronic total occlusion, and small-vessel stenting. ADP-induced platelet aggregation was serially measured by light transmission aggregometry at least three times after PCI and the mean value was calculated. The population was categorized on the basis of the mean ADP degree and the presence of CPCI. The primary endpoint measured was a major adverse cardiovascular and cerebral event (MACCE). Results A total of 1245 patients enrolled in the study were divided into four groups: group A (CPCI and ADP≥40%), group B (CPCI and ADP<40%), group C (non-CPCI and ADP≥40%), and group D (non-CPCI and ADP<40%). The median follow-up was 29.9 months. The Cox multivariate analysis suggested that group A was an independent risk factor for MACCE (hazard ratio: 2.70, 95% confidence interval: 1.25–5.81; P<0.001). Compared with group A, the remaining groups (groups B, C, and D) had a lower rate of MACCE. When group C was set as the reference, groups B and D had similar risks for primary endpoints. Conclusion Patients undergoing CPCI with a high mean ADP degree are at a high risk for MACCE. Serial platelet function testing is therefore important in patients receiving CPCI.

Unprotected left main coronary artery disease after revascularization : effect of diabetes on patient outcomes.

ObjectiveIt is unknown whether the effect of diabetes on patients with unprotected left main coronary artery (LMCA) disease differs according to the different revascularization strategies. This study was conducted to evaluate the impact of diabetes on patients with unprotected LMCA disease treated with either percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG).Patients and methodsWe prospectively enrolled 823 consecutive patients with unprotected LMCA disease who had drug-eluting stent (DES; n = 331) implantation or underwent CABG (n = 492) in the study. We compared the effects of diabetes on clinical outcomes according to different revascularization strategies.ResultsAmong 823 eligible patients enrolled, 226 had diabetes. In the DES population, no significant differences were observed in occurrences of death, cardiac death, repeat revascularization, stroke, and major adverse cardiac and cerebrovascular events. However, the risks of the composite of death/myocardial infarction (MI)/stroke (21.5 % DM vs. 7.2 % non-DM; p = 0.001) and MI (15.4 % DM vs. 1.6 % non-DM; p = 0.000) were significantly higher in the diabetic patients than those without diabetes. In the CABG population, similar rates of all clinical endpoints were observed between the diabetic and nondiabetic group.ConclusionDiabetes was associated with worse outcome in patients undergoing DES implantation for the treatment of unprotected LMCA disease. However, its negative prognostic impact was not found among patients undergoing CABG.ZusammenfassungZielOb sich die Auswirkungen eines Diabetes mellitus auf Patienten mit koronarer Herzkrankheit (KHK) des ungeschützten Hauptstamms (LMCA) bei verschiedenen Revaskularisierungsstrategien unterscheiden, ist nicht bekannt. Die vorliegende Studie wurde durchgeführt, um den Einfluss eines Diabetes auf Patienten mit KHK des ungeschützten LMCA zu untersuchen, die entweder mittels perkutaner Koronarintervention (PCI) oder mit einem Koronarbypass (CABG) behandelt wurden.MethodenAn der Studie nahmen 823 konsekutive Patienten mit KHK des ungeschützten LMCA teil, bei denen die Versorgung mit der Implantation von medikamentenfreisetzenden Stents (DES, n = 331) oder einem CABG (n = 492) erfolgte. Es wurden die Auswirkungen eines Diabetes auf klinische Ergebnisse in Abhängigkeit von den verschiedenen Revaskularisierungsstrategien verglichen.ErgebnisseVon 823 für die Studie geeigneten Patienten wiesen 226 einen Diabetes mellitus (DM) auf. In der DES-Gruppe wurden keine signifikanten Unterschiede hinsichtlich des Auftretens von Todesfällen, Herztod, wiederholter Revaskularisierung, Schlaganfall und schweren unerwünschten kardialen und zerebrovaskulären Ereignissen (MACCE) beobachtet. Allerdings war das Risiko für den zusammengesetzten Endpunkt aus Tod/Herzinfarkt/Schlaganfall (21,5 % DM vs. 7,2 % ohne DM; p = 0,001) und Herzinfarkt (15,4 % DM vs. 1,6 % ohne DM; p = 0,000) bei Patienten mit Diabetes signifikant höher als bei Patienten ohne. In der CABG-Gruppe wurden ähnliche Raten aller klinischen Endpunkte für die Gruppen mit und ohne Diabetes beobachtet.SchlussfolgerungEin Diabetes mellitus stand mit einem schlechteren Ergebnis bei Patienten mit DES-Implantation zur Therapie einer KHK des ungeschützten LMCA in Zusammenhang. Jedoch war der negative prognostische Einfluss des Diabetes nicht bei Patienten mit CABG festzustellen.

Unprotected left main coronary artery disease after revascularization@@@Koronare Herzkrankheit des ungeschützten linken Hauptstamms nach Revaskularisierung: Effect of diabetes on patient outcomes@@@Einfluss von Diabetes mellitus auf das Ergebnis für den Patienten

ObjectiveIt is unknown whether the effect of diabetes on patients with unprotected left main coronary artery (LMCA) disease differs according to the different revascularization strategies. This study was conducted to evaluate the impact of diabetes on patients with unprotected LMCA disease treated with either percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG).Patients and methodsWe prospectively enrolled 823 consecutive patients with unprotected LMCA disease who had drug-eluting stent (DES; n = 331) implantation or underwent CABG (n = 492) in the study. We compared the effects of diabetes on clinical outcomes according to different revascularization strategies.ResultsAmong 823 eligible patients enrolled, 226 had diabetes. In the DES population, no significant differences were observed in occurrences of death, cardiac death, repeat revascularization, stroke, and major adverse cardiac and cerebrovascular events. However, the risks of the composite of death/myocardial infarction (MI)/stroke (21.5 % DM vs. 7.2 % non-DM; p = 0.001) and MI (15.4 % DM vs. 1.6 % non-DM; p = 0.000) were significantly higher in the diabetic patients than those without diabetes. In the CABG population, similar rates of all clinical endpoints were observed between the diabetic and nondiabetic group.ConclusionDiabetes was associated with worse outcome in patients undergoing DES implantation for the treatment of unprotected LMCA disease. However, its negative prognostic impact was not found among patients undergoing CABG.ZusammenfassungZielOb sich die Auswirkungen eines Diabetes mellitus auf Patienten mit koronarer Herzkrankheit (KHK) des ungeschützten Hauptstamms (LMCA) bei verschiedenen Revaskularisierungsstrategien unterscheiden, ist nicht bekannt. Die vorliegende Studie wurde durchgeführt, um den Einfluss eines Diabetes auf Patienten mit KHK des ungeschützten LMCA zu untersuchen, die entweder mittels perkutaner Koronarintervention (PCI) oder mit einem Koronarbypass (CABG) behandelt wurden.MethodenAn der Studie nahmen 823 konsekutive Patienten mit KHK des ungeschützten LMCA teil, bei denen die Versorgung mit der Implantation von medikamentenfreisetzenden Stents (DES, n = 331) oder einem CABG (n = 492) erfolgte. Es wurden die Auswirkungen eines Diabetes auf klinische Ergebnisse in Abhängigkeit von den verschiedenen Revaskularisierungsstrategien verglichen.ErgebnisseVon 823 für die Studie geeigneten Patienten wiesen 226 einen Diabetes mellitus (DM) auf. In der DES-Gruppe wurden keine signifikanten Unterschiede hinsichtlich des Auftretens von Todesfällen, Herztod, wiederholter Revaskularisierung, Schlaganfall und schweren unerwünschten kardialen und zerebrovaskulären Ereignissen (MACCE) beobachtet. Allerdings war das Risiko für den zusammengesetzten Endpunkt aus Tod/Herzinfarkt/Schlaganfall (21,5 % DM vs. 7,2 % ohne DM; p = 0,001) und Herzinfarkt (15,4 % DM vs. 1,6 % ohne DM; p = 0,000) bei Patienten mit Diabetes signifikant höher als bei Patienten ohne. In der CABG-Gruppe wurden ähnliche Raten aller klinischen Endpunkte für die Gruppen mit und ohne Diabetes beobachtet.SchlussfolgerungEin Diabetes mellitus stand mit einem schlechteren Ergebnis bei Patienten mit DES-Implantation zur Therapie einer KHK des ungeschützten LMCA in Zusammenhang. Jedoch war der negative prognostische Einfluss des Diabetes nicht bei Patienten mit CABG festzustellen.