Sudhakar Sattur

A Comparison of Contemporary Definitions of Contrast Nephropathy in Patients Undergoing Percutaneous Coronary Intervention and a Proposal for a Novel Nephropathy Grading System

Contrast-induced nephropathy (CIN) after percutaneous coronary intervention (PCI) has multiple definitions. We attempted to identify the optimal definition of CIN. In 985 patients undergoing PCI (derivation group), we assessed the prognostic significance of 4 commonly used contemporary definitions of CIN (increases in serum creatinine after PCI [deltaCr] >1.0 mg/dl, >0.5 mg/dl, and >25% after PCI; and the American College of Cardiology National Cardiovascular Data Registry definition) with respect to 6-month major adverse cardiovascular events (MACEs) and all-cause mortality (at 863 +/- 324 days). Incidence of CIN ranged widely (2.0% to 15%) depending on the definition used. Only 2 definitions (deltaCr >0.5 mg/dl, >25%) consistently correlated with study outcomes. Using these 2 definitions, we devised a new grading system (grade 0 deltaCr <or=25% and <or=0.5 mg/dl; grade 1 deltaCr >25% but <or=0.5 mg/dl; and grade 2 deltaCr >0.5 mg/dl). Nephropathy grades (0 vs 1 vs 2) showed significant correlation with 6-month MACEs (12.4 vs 19.4 vs 28.6%, p = 0.003) and all-cause mortality (10.2 vs 10.4 vs 40.9%, p <0.0001). In multivariate analyses, the grading system showed an independent association with MACEs and mortality. The prognostic value of nephropathy grades was prospectively confirmed in an independent validation group of 539 patients. In conclusion, of the 4 contemporary definitions of CIN, only deltaCr >25% and >0.5 mg/dl consistently predicted adverse events after PCI. By unifying these 2 definitions, we devised a novel nephropathy grading system that is predictive of 6-month MACEs and all-cause mortality after PCI.

Pharmacologic Therapy for Reducing Myocardial Infarct Size in Clinical Trials Failed and Promising Approaches

In patients with acute ST-segment elevation myocardial infarction, early, successful, and durable reperfusion therapy optimizes the likelihood of favorable outcomes. Fibrinolysis and primary percutaneous coronary intervention improve survival compared to no reperfusion therapy in large part by reducing infarct size (IS) and preserving left ventricular ejection fraction. There is direct correlation between IS and clinical outcomes. In this article, we will review some of the more promising pharmacological agents geared toward reduction in IS, discuss the major pathways that can lead to this desirable outcome, and evaluate the results of clinical trials performed with these and other compounds.

Utilization Patterns of Single‐Photon Emission Cardiac Tomography Myocardial Perfusion Imaging Studies in a Rural Tertiary Care Setting

Appropriate use criteria (AUC) for single‐photon emission computed tomographic myocardial perfusion imaging (SPECT MPI) were revised in 2009 to include 15 new clinical scenarios. We assessed multivariable predictors and overall appropriateness of MPI studies performed in a rural tertiary care setting.

Long-Term Safety and Effectiveness of Drug-Eluting Stents Compared to Bare Metal Stents following Successful PCI in Non-ST-Elevation Myocardial Infarction: Findings from the Guthrie Health Off-Label StenT (GHOST) Registry

BACKGROUND The long-term safety and effectiveness of drug-eluting stents (DES) versus bare metal stents (BMS) in non-ST-segment elevation myocardial infarction (NSTEMI) beyond 2 years after percutaneous coronary intervention (PCI) is unknown. METHODS  We studied 674 NSTEMI patients who underwent successful PCI with DES (n = 323) or BMS (n = 351). The primary study end-points were time to occurrence of death or nonfatal recurrent myocardial infarction (MI), and stent thrombosis (ST). Secondary end-points included time to occurrence of target vessel revascularization (TVR) and any major adverse cardiovascular event (MACE, defined as the composite of death, MI, ST, TVR). RESULTS  The DES and BMS groups were well matched except that DES patients received dual antiplatelet therapy for a longer duration and had smaller final vessel diameter. In survival analysis, at a mean follow-up of 1333 ± 659 days after PCI, the DES group had similar incidence of death/myocardial infarction (24% vs. 27%, log rank p = 0.23) and ST (4.0% vs. 2.6%, p = 0.18) as the BMS group. The DES patients had lower incidence of TVR (8.1% vs. 17%, p = 0.0018) but similar MACE (26% vs. 37%, p = 0.31). In multivariable analysis, DES vs. BMS implantation showed no significant impact on death/myocardial infarction [adjusted hazards ratio (HR) 1.0, 95% confidence intervals (CI) 0.7-1.4], ST (HR 1.7; CI 0.7 - 4.0), or MACE (HR 0.8; CI 0.6 - 1.1). However, TVR was lower in the DES group (HR 0.4; CI 0.3 - 0.7). CONCLUSION In patients presenting with NSTEMI, DES implantation appears to be as safe as BMS implantation at long-term follow-up. In addition, DES are effective in reducing TVR compared to BMS.

Long-Term Safety and Effectiveness of Drug-Eluting Stents Compared to Bare Metal Stents in ST Elevation Myocardial Infarction: Findings from the Guthrie Health Off-Label Stent (GHOST) Registry

BACKGROUND Multiple randomized trials and observational studies have shown drug-eluting stents (DES) to be safe and effective at 3-year follow-up in stent thrombosis (ST)-segment elevation myocardial infarction (STEMI) treated with primary percutaneous coronary intervention (PCI). However, outcomes data beyond 3-4 years after DES implantation are sparse. METHODS We studied 554 STEMI patients who underwent successful PCI with either DES or bare metal stent (BMS). Primary study end-points were time to occurrence of ST and the composite of death or myocardial infarction (MI). Secondary end-points were time to occurrence of major adverse cardiac events (MACEs) and discrete events that comprise MACE (death, MI, and target vessel revascularization [TVR]). Outcomes of the DES and BMS groups were assessed by survival analysis and multivariable Cox regression. RESULTS There were 205 (37%) patients who received DES and 349 (63%) patients who received BMS. At a median follow-up of 41.4 months after PCI, there were no differences in the unadjusted incidence of ST (ST, 3.4 vs. 4.3%, log-rank P = 0.61) and MI (6.8% vs. 8%, P = 0.61) between DES versus BMS groups, respectively. However, DES implantation was associated with lower unadjusted incidence of death or MI (11% vs. 23.5%, P = 0.0002), MACE (16% vs. 34%, P < 0.0001), death (6.3% vs. 17%, P = 0.0004), and TVR (9.8% vs. 18%, P = 0.008) than BMS implantation. In multivariable analyses, DES implantation was associated with significantly lower incidence of MACE (adjusted HR = 0.47 [95% CI: 0.31-0.76], P = 0.0007) than BMS implantation. CONCLUSION In our study of STEMI patients, DES implantation was safer than BMS implantation and was associated with lower MACE at long-term follow-up.

Renal Artery Stenosis-An Update

Abstract Renal artery stenosis (RAS) is a common form of peripheral arterial disease. The most common cause of RAS is atherosclerosis. It is predominantly unilateral. The pathophysiologic mechanism stems from renal underperfusion resulting in the activation of the renin- angiotensin-aldosterone pathway. Even though the majority of patients with RAS are asymptomatic, it can clinically present with hypertension, nephropathy and congestive heart failure. This progressive disease can lead to resistant hypertension and end stage kidney failure. Screening patients for RAS with either Doppler ultrasonography, computed tomographic angiography, or magnetic resonance angiography is preferred. Adequate blood pressure control, goal-directed lipid-lowering therapy, smoking cessation, and other preventive measures form the foundation of management of patients with RAS. Catheter-based percutaneous revascularization with angioplasty and stenting showed modest clinical benefit for patients in small retrospective studies, but data from randomized clinical trials failed to confirm these beneficial results. The current ongoing Cardiovascular Outcomes in Renal Atherosclerotic Lesions (CORAL) trial may provide more concrete data regarding the role of stenting in RAS. Surgical revascularization is considered only if catheter-based revascularization is unsuitable or unsuccessful. The American College of Cardiology/American Heart Association guidelines on evaluation and management of patients with RAS provide the framework for determining individualized assessment and treatment plans for patients with RAS.

A Bayesian network meta-analysis of PCSK9 inhibitors, statins and ezetimibe with or without statins for cardiovascular outcomes

Background The comparative effects of statins, ezetimibe with or without statins and proprotein convertase subtilisin-kexin type 9 (PCSK9) inhibitors remain unassessed. Design Bayesian network meta-analysis was conducted to compare treatment groups. Methods Thirty-nine randomized controlled trials were selected using MEDLINE, EMBASE, and CENTRAL (inception – September 2017). Results In network meta-analysis of 189,116 patients, PCSK9 inhibitors were ranked as the best treatment for prevention of major adverse cardiovascular events (Surface Under Cumulative Ranking Curve (SUCRA), 85%), myocardial infarction (SUCRA, 84%) and stroke (SUCRA, 80%). PCSK9 inhibitors reduced the risk of major adverse cardiovascular events compared with ezetimibe + statin (odds ratio (OR): 0.72; 95% credible interval (CrI), 0.55–0.95; Grading of Recommendation Assessment, Development and Evaluation (GRADE) criteria: moderate), statin (OR: 0.78; 95% CrI: 0.62–0.97; GRADE: moderate) and placebo (OR: 0.63; 95% CrI: 0.49–0.79; GRADE: high). The PCSK9 inhibitors were consistently superior to groups for major adverse cardiovascular event reduction in secondary prevention trials (SUCRA, 95%). Statins had the highest probability of having lowest rates of all-cause mortality (SUCRA, 82%) and cardiovascular mortality (SUCRA, 84%). Compared with placebo, statins reduced the risk of all-cause mortality (OR: 0.88; 95% CrI: 0.83–0.94; GRADE: moderate) and cardiovascular mortality (OR: 0.84; 95% CrI: 0.77–0.90; GRADE: high). For cardiovascular mortality, PCSK9 inhibitors were ranked as the second best treatment (SUCRA, 78%) followed by ezetimibe + statin (SUCRA, 50%). Conclusion PCSK9 inhibitors were ranked as the most effective treatment for reducing major adverse cardiovascular events, myocardial infarction and stroke, without having major safety concerns. Statins were ranked as the most effective therapy for reducing mortality.

Arteriotomy site complication during transcatheter aortic valve replacement: Ipsilateral wire protection and bailout

Major vascular complications still occur in ~4.2% of transcatheter aortic valve replacement (TAVR) procedures. These complications are a major safety drawback of TAVR when compared to surgical aortic valve replacement (SAVR). Contemporary strategies designed to minimize and effectively treat vascular complications are of immense importance to a successful TAVR program. This review discusses strategies to optimize TAVR access and device choice along with TAVR access complication management. Iliac complications are less frequently encountered and can be managed effectively via the TAVR sheath over the TAVR wire employing ipsilateral proximal iliac balloon occlusion and endovascular repair. The more common arteriotomy site complications and access site closure failure require prophylactic or bail-out common femoral to superficial femoral artery wiring. Suggested is a novel method of ipsilateral arteriotomy site protection that is safe, simple and does not require additional resources. Ipsilateral wiring can also be done prophylactically or as a bailout in case of arteriotomy site complication.

CONTAINED ANNULAR RUPTURE FOLLOWING TRANSCATHETER AORTIC VALVE REPLACEMENT: A RARE COMPLICATION WITH AN UNUSUAL PRESENTATION

Annular rupture is a potential fatal complication identified during the Transcatheter Aortic Valve Replacement (TAVR) procedure. We present a rare case of contained annular rupture presenting as syncope during follow up. A 76-year-old male with heavily calcified, severe AS with high surgical risk

Meta-analysis of efficacy and safety of dual antiplatelet therapy versus aspirin monotherapy after coronary artery bypass grafting.

About seven million patients suffer with acute myocardial infarction (AMI) worldwide with 20% experiencing a second cardiovascular (CV) event in the first year. However despite such a significant disease burden, preventive strategies against major adverse cardiovascular events (MACEs) remain suboptimal. The EUROASPIRE surveys across Europe suggest that among patients with a high CV risk or patients with established coronary artery disease, there is lack of healthy life style or adequate use of drug therapies to improve CV outcomes. Aspirin (ASA) monotherapy is considered as the standard of care to prevent graft occlusion and MACEs following coronary artery bypass grafting (CABG). While dual antiplatelet therapy (DAPT) is recommended in acute coronary syndrome (ACS) after revascularization, the potential impact of DAPT on saphenous vein graft (SVG) patency and MACE after CABG remains uncertain. Recent randomized controlled trials (RCTs) have suggested superior efficacy of DAPT over ASA in maintaining graft patency at one year. To update the evidence, we conducted a meta-analysis comparing DAPT vs ASA in patients following CABG at one-year follow-up. Five RCTs (837 patients) were identified by searching MEDLINE, EMBASE, and CENTRAL from inception of the databases to April 2018 (Table 1). The data was abstracted on baseline characteristics of the participants and key outcomes. The risk of bias was assessed on the Cochrane bias risk assessment tool. The literature search, screening of the articles, and data abstraction were performed by ST and ML independently. The primary outcome was MACEs (composite of myocardial infarction (MI), stroke and all-cause mortality). Secondary outcomes were components of MACE and CV mortality, SVG occlusion, and major bleeding. The meta-analysis was performed using DerSimonian and Laird random effects models. Estimates were reported as risk differences (RDs) with 95% confidence intervals (CIs). Statistical significance was set at 0.05. Heterogeneity was quantified via the I test and values >75% were consistent with a high degree of heterogeneity. Publication bias was assessed using Egger’s test. Comprehensive meta-analysis software version 3.0 (Biostat, Englewood, New Jersey, USA) was used for all analyses. DAPT was associated with significant absolute risk reduction in MACEs (RD, 0.033, 95% CI, 0.061, 0.005, p1⁄4 0.02, I1⁄4 0) and stroke (RD, 0.019, 95% CI, 0.037, 0.001, p1⁄4 0.04, I1⁄4 0) compared with ASA. There were no significant differences between both groups in terms of MI or all-cause mortality (Figure 1). DAPT had no significant effects on SVG occlusion (RD, 0.041, 95% CI, 0.133, 0.050, p1⁄4 0.37, I1⁄4 0), CV mortality (RD, 0.009, 95% CI, 0.027, 0.009, p1⁄4 0.33, I1⁄4 0), or major bleeding (RD, 0.005, 95% CI, 0.008, 0.018, p1⁄4 0.75, I1⁄4 0). Egger’s test did not detect publication bias (p (twotailed)1⁄4 0.68). Current meta-analysis suggests that there was one fewer patient experiencing MACEs for every 30 patients and one fewer case of stroke for every 52 patients treated with DAPT for one year following CABG. These benefits were achieved without increasing the risk of major bleeding. Stroke remains a major