Shi-Jian Chen

Meta-Analysis of Relation Between Oral β-Blocker Therapy and Outcomes in Patients With Acute Myocardial Infarction Who Underwent Percutaneous Coronary Intervention

The aim of the present review was to investigate the association between the use of oral β-blockers and prognosis in patients with acute myocardial infarction (AMI) who underwent percutaneous coronary intervention (PCI) treatment. A systematic literature search was conducted in Pubmed (from inception to September 27, 2014) and Embase (Ovid SP, from 1974 to September 29, 2014) to identify studies that compared the outcome of patients with AMI taking oral β-blockers with that of patients not taking after PCI. Systematic review and meta-analysis were performed with random-effects model or fixed-effects model. Ten observational studies with a total of 40,873 patients were included. Use of β-blockers was associated with a reduced risk of all-cause death (unadjusted relative risk 0.58, 95% confidential interval 0.48 to 0.71; adjusted hazard ratio 0.76, 95% confidential interval 0.62 to 0.94). The potential benefit of β-blockers in preventing all-cause death was not similar in all population but was restricted to those with reduced ejection fraction, with low use proportion of other secondary prevention drugs or with non-ST-segment elevation myocardial infarction. The association between the use of β-blockers and improved survival rate was significant in ≤1-year follow-up duration. Rates of cardiac death, myocardial infarction, and heart failure readmission in patients using β-blockers were not significantly different from those in patients without β-blocker therapy. In conclusion, there is lack of evidence to support routine use of β-blockers in all patients with AMI who underwent PCI. Further trials are urgently needed to address the issue.

The correlation between serum total bilirubin and outcomes in patients with different subtypes of coronary artery disease

BACKGROUNDS The relation between serum total bilirubin (TBi) and mortality in patients with established coronary artery disease (CAD) remains undefined. We try to investigate the role of the subtypes of CAD in the association. METHODS A total of 3013 patients with angiographically obstructive CAD were enrolled. A retrospective analysis was conducted. Patients were divided into 3 groups as follows: stable CAD (SCAD), unstable angina pectoris (UAP) and acute myocardial infarction (AMI). The predictive values of TBi for 30-day and long-term mortality were assessed using logistic and Cox regression, respectively. RESULTS Higher initial serum TBi levels were significantly associated with increased risk of short-term mortality (OR 2.35, 95% CI 1.15-4.77) in AMI group. However, the association was absent among patients with SCAD and UAP. Serum TBi was able to independently predict the long-term mortality in SCAD (HR 0.34, 95% CI 0.16-0.70) and UAP (HR 0.49, 95% CI 0.31-0.78) groups. However, there was no significant relation between TBi and long-term mortality in AMI groups. CONCLUSION The different subtypes of CAD affected the relation between serum TBi and clinical prognosis. Initial serum TBi was positively correlated with short-term mortality of AMI patients, and negatively correlated with long-term mortality in SCAD or UAP patients.

A two‐stage hybrid approach for complex aortic coarctation combined with ascending‐descending aorta dilatation and concomitant aortic valve regurgitation

We present a case of aortic coarctation combined with ascending‐descending aorta dilatation and concomitant aortic valve regurgitation. The technique involved using endovascular stenting, a two‐stage balloon dilation procedure post‐stent implantation and a Bentall procedure.

The effect of activated clotting time values for patients undergoing percutaneous coronary intervention: A systematic review and meta-analysis

Our aim was to illustrate the effect of higher activated clotting time (ACT) values versus lower ACT values on thrombotic or hemorrhagic events in coronary atherosclerotic heart disease (CHD) patients undergoing percutaneous coronary intervention (PCI). PubMed, Embase, Web of Science, and Cochrane Library were searched. Observational studies assessing ACT related major adverse cardiac event (MACE) and major bleeding were included. Studies were allocated into three groups. Group 1 included studies with low percentage of participants prescribed with glycoprotein IIb/IIIa inhibitors ([GPI] ≤30%), Group 2 with high percentage of participants prescribed with GPI (>30%), and Group 3 with routine direct thrombin inhibitors (DTI) prescription. The cutoff is designed as 300s (290-310s) for Group 1, and 250s (240-260s) for Group 2. With regard to MACE and major bleeding in Group 1, there was no significant difference between higher ACT values and lower ACT values (risk ratio [RR] for MACE, 1.16, 95% confidence interval [CI], 0.65-2.05, p=0.62, I(2)=94%, RR for major bleeding, 0.96, 95% CI, 0.66-1.40, p=0.83, I(2)=0%). Likewise, no significant difference was found in Group 2 between higher ACT values and lower ACT values (RR for MACE, 1.15, 95% CI, 0.97-1.35, p=0.10, I(2)=0%, RR for major bleeding, 0.85, 95% CI, 0.45-1.60, p=0.61, I(2)=83%). In conclusion, ACT may not have a substantial effect on thrombotic or hemorrhagic complications. Under current clinical practice, target ACT may be higher than what is necessary to prevent thrombotic events. We may achieve a relative low ACT level to preserve efficacy and enhance safety.

Influence of Renal Insufficiency on the Prescription of Evidence-Based Medicines in Patients With Coronary Artery Disease and Its Prognostic Significance: A Retrospective Cohort Study

AbstractThe purpose of this study was to discuss the present situation of discharge medications in coronary artery disease (CAD) patients with different levels of renal function and assess the potential impact of these medications on the prognosis of this patient population.A retrospective cohort study was conducted. From July 2008 to Jan 2012, consecutive patients with CAD confirmed by coronary angiography of West China Hospital were enrolled and were grouped into 3 estimated glomerular filtration rate (eGFR) categories: ≥60, 30 to 60, and <30 mL/min/1.73 m2. The endpoints were all-cause mortality and cardiac mortality.There are 3002 patients according to the inclusion criteria and follow-up requirement. The mean follow-up time was 29.1 ± 12.5 months. CAD patients with worse renal function included more cardiovascular risk factors (advanced age, history of hypertension or diabetes, and diagnosis of acute myocardial infarction). The cumulative survival curves of the patients according to renal function showed that the eGFR <30 mL/min and 30 mL/min ⩽ eGFR <60 mL/min groups had a significantly higher risk of all-cause death and cardiovascular death than the group with an eGFR ≥60 mL/min. The prescription of evidence-based medicines (EBMs) at discharge (antiplatelet agents, beta-blockers, statins, and angiotensin-converting enzyme inhibitors [ACEIs] or angiotensin-receptor blockers [ARBs]) was a factor in reducing the risk of all-cause death and cardiovascular death. However, EBMs prescribed at discharge revealed an obvious underuse in renal insufficiency (RI) patients. The results of Cox regression showed that irrespective of the eGFR level, greater use of EBMs resulted in a greater reduction in the risk of all-cause death and cardiovascular death.A higher percentage of patients with CAD and concomitant RI suffered from cardiovascular disease (CVD) risk factors, whereas a lower percentage of these patients used EBMs to prevent CVD events. Strict use of EBMs, including beta-blockers, statins, and ACEIs or ARBs, can lead to more clinical benefits, even for patients with CAD and concomitant RI. Thus, treatment of this patient population with EBMs should be stressed.

Association Between Bisphosphonates Therapy and Incident Myocardial Infarction: Meta-analysis and Trial Sequential Analysis.

Background: Bisphosphonates have shown potential to inhibit atherosclerosis in animal experiments; however, whether bisphosphonates therapy lowers the risk of incidence of myocardial infarction (MI) is debated. We performed the meta-analysis and trial sequential analysis (TSA) to investigate the relation between bisphosphonates therapy and incident MI. Methods: Pubmed and Embase databases were systematically searched in April 2015 to identify studies, which compared the incidence of MI in subjects receiving bisphosphonates with that in subjects not receiving the agents. Meta-analysis was conducted using random effects model in consideration of statistical heterogeneity between studies. Reliability of the results from meta-analysis was examined using TSA. Results: Six observational studies (n = 440261) and 3 randomized control trials (RCTs, n = 11,024) met the eligible criteria. In the pooled analysis of observational studies, bisphosphonates therapy was not associated with reduced risk of MI either using unadjusted estimates (relative risk 0.93, 95% confidence interval (CI), 0.75–1.15) or estimates adjusted for confounding factors (hazard ratio 1.01, 95% CI, 0.84–1.21). Furthermore, hazard of incident MI did not differ between alendronate users and nonusers. TSA showed that evidence from observational studies firmly precluded the association between bisphosphonates and incident MI. Pooled analysis of RCTs also suggested no benefits of decrease in incident MI associated with bisphosphonates therapy (relative risk 1.05, 95% CI, 0.53–2.09). However, TSA demonstrated that evidence from RCTs was insufficient to draw a conclusion. Conclusions: Despite the encouraging findings from animal studies, bisphosphonates therapy is not associated with reduced risk of MI.

Prevalence and Prognostic Significance of Right Ventricular Dysfunction in Patients With Hypertrophic Cardiomyopathy

Few data are available regarding the prevalence and clinical significance of right ventricular systolic dysfunction (RVSD) in hypertrophic cardiomyopathy (HC) patients. This study aimed to evaluate right ventricular (RV) systolic function by cardiovascular magnetic resonance and explore the prevalence and prognostic significance of RVSD in HC patients. A total of 226 patients with HC assessed by cardiovascular magnetic resonance were included in this retrospective study. RVSD was defined by RV ejection fraction (RVEF) ≤45% and was present in 26 (11.5%) patients. Association between RVSD, clinical characteristics, and outcomes were analyzed. RVEF was significantly lower in patients with RVSD than without RVSD (36.2 ± 7.0% vs 60.5 ± 7.4%, p < 0.001). There was a positive correlation between RVEF and left ventricular ejection fraction (r = 0.45; p < 0.001). During a mean follow-up of 30.5 ± 23.9 months, there were 22 (9.7 %) all-cause mortality, including 12 (5.3%) cardiovascular death. Kaplan-Meier analysis showed a significantly higher risk for cardiovascular mortality in patients with RVSD (p = 0.026), but no significant difference in all-cause mortality (p = 0.118) and heart failure related rehospitalization (p = 0.485). On multivariate Cox regression analysis, RVSD (hazard ratio 5.36; confidence interval 1.39 to 20.77; p = 0.015) and RVEF (hazard ratio 0.94; confidence interval 0.89 to 0.98; p = 0.011) were independent predictors of cardiovascular mortality. In conclusion, RVSD is a common phenotype and a strong independent predictor of cardiovascular mortality in HC patients.

Fibrinogen is related to long-term mortality in Chinese patients with acute coronary syndrome but failed to enhance the prognostic value of the GRACE score

Fibrinogen (Fib) is considered to be a potential risk factor for the prognosis of patients with acute coronary syndrome (ACS), but it is unclear whether Fib level have synergistic effects to enhance the prognostic value of the GRACE score in patients with ACS. A retrospective analysis was conducted from a single registered database. 2253 consecutive patients with ACS confirmed by coronary angiography were enrolled and were grouped into 3 categories by the tertiles of admission plasma Fib levels. The end points were all-cause mortality and cardiac mortality. The mean follow-up time was 27.2 ± 13.1 months and death events occurred in 223 cases and cardiac death events occurred in 130 cases. Cumulative survival curves indicated that the risk of all-cause death increased with increasing Fib level (mortality rates for Tertile 1 vs. Tertile 2 vs. Tertile 3 = 6.6% vs. 10.8 %vs. 12.3%, p < 0.001). Cox multivariate regression analysis indicated that compared with other traditional risk factors, plasma Fib level is independently correlated with all-cause death (HR 1.33, 95% CI 1.04-1.70). However, incorporating elevated Fib level into the GRACE model did not significantly increase the predictive value of the GRACE score; for instance, AUC only increased from 0.703 to 0.713 (p = 0.765). In conclusion, Fib level at admission was independently associated with death risk among Chinese patients with ACS. However, the incorporation of Fib level at admission into the GRACE score did not improve this score’s predictive value for death risk among these patients.

Two-stage hybrid treatment strategy for an adult patient with aortic arch coarctation, poststenotic aneurysm, and hypoplastic left subclavian artery: A case report

Rationale: Coarctation of aorta in adulthood is usually complicated by other cardiovascular anomalies, posing great technical challenge for intervention. Patient concerns: Here, we report an extremely rare case of aortic arch coarctation combined with a poststenotic biloculated calcified aneurysm and hypoplastic left subclavian artery. Interventions: First, an extra-anatomic bypass was established, along with narrowing of aorta just proximal and distal to the aneurysm. While the bypass graft significantly relieved trans-coarctation gradient, the latter procedure decreased intra-aneurysm pressure and created landing zones for aneurysm occlusion. Six months later, 2 muscular ventricular septal defect occluders were deployed at the proximal and distal orifice of the aneurysm. Outcomes: Follow-up computed tomography angiography confirmed the absence of contrast leakage into aneurysm. Conclusions: A 2-stage hybrid approach described here appears to be feasible, safe, and associated with favorable clinical outcomes in the treatment of complicated aortic coarctation and poststenotic aneurysm.

The safety of concomitant transcatheter aortic valve replacement and percutaneous coronary intervention: A systematic review and meta-analysis

Background: TAVR is a rapidly spreading treatment option for severe aortic valve stenosis. Significant coronary artery disease (CAD) is present in 40% to 75% of patients undergoing TAVR. However, when to treat the concomitant coronary artery lesions is controversial. Methods: This is a systematic review comparing concomitant PCI and TAVR versus staged PCI and TAVR. The OVID database was systematically searched for studies reporting PCI in patients undergoing TAVR. A random effects model was used to calculate the pooled odds ratio (OR) with 95% confidence intervals. Results: Four observational studies and a total of 209 patients were included in this analysis. Overall 30-day mortality was similar between concomitant PCI and TAVR versus staged PCI and TAVR [OR: 1.47 (0.47–4.62); P = .51], renal failure was not significantly different between both groups [OR: 3.22 (0.61–17.12); P = .17], periprocedural myocardial infarction was not different between the 2 groups [OR: 1.44 (0.12–16.94); P = .77], life-threatening bleeding did not differ between both groups [OR: 0.45 (0.11–1.87); P = .27], and major stroke also was not significantly different [OR: 3.41 (0.16–74.2); P = .44]. Conclusion: These data did not show a significant difference in short-term outcomes between concomitant PCI and TAVR versus staged PCI and TAVR.