Tarique Zaman

Heavy metals and cardiovascular disease: results from the National Health and Nutrition Examination Survey (NHANES) 1999-2006.

We assessed the role of lead and cadmium as partial mediators between smoking and composite cardiovascular and cerebrovascular disease (CCVD). We also studied the association between urinary heavy metals and CCVD. Pooled data from NHANES 1999-2006 were examined. Cardiovascular and cerebrovascular disease was determined using a standardized questionnaire asking about history of stroke, angina, heart attack, coronary artery disease, and congestive heart failure. Increasing serum cadmium levels were associated with increasing prevalence of CCVD (P-trend: .03). Adjusted odds-ratio (OR) for active smokers versus never smokers was 2.09 (1.67-2.63). Adjustment for lead did not affect the OR but adjustment for cadmium significantly attenuated the OR (1.54 [1.17-2.03]). Significant association was observed between CCVD and urinary antimony, cadmium, cobalt, and tungsten. High levels of serum cadmium (>0.61 µg/L) were associated with CCVD. The relationship between smoking and CCVD was partially mediated through cadmium. Urinary antimony, cadmium, cobalt, and tungsten may be associated with CCVD.

Percutaneous coronary intervention in patients with severe aortic stenosis: implications for transcatheter aortic valve replacement.

Background— With the availability of transcatheter aortic valve replacement, management of coronary artery disease in patients with severe aortic stenosis (AS) is posing challenges. Outcomes of percutaneous coronary intervention (PCI) in patients with severe AS and coronary artery disease remain unknown. We sought to compare the short-term outcomes of PCI in patients with and without AS. Methods and Results— From our PCI database, we identified 254 patients with severe AS who underwent PCI between 1998 and 2008. Using propensity matching, we found 508 patients without AS who underwent PCI in the same period. The primary end point of 30-day mortality after PCI was similar in patients with and without severe AS (4.3% [11 of 254] versus 4.7% [24 of 508]; hazard ratio, 0.93; 95% confidence interval, 0.51–1.69; P=0.2). Patients with low ejection fraction (⩽30%) and severe AS had a higher 30-day post-PCI mortality compared with those with an ejection fraction >30% (5.4% [7 of 45] versus 1.2% [4 of 209]; P<0.001). In addition, AS patients with high Society of Thoracic Surgeons score (≥10) had a higher 30-day post-PCI mortality than those with a Society of Thoracic Surgeons score <10 (10.4% [10 of 96] versus 0%; P<0.001). Conclusions— PCI can be performed in patients with severe symptomatic AS and coronary artery disease without an increased risk of short-term mortality compared with propensity-matched patients without AS. Patients with ejection fraction ⩽30% and Society of Thoracic Surgeons score ≥10% are at a highest risk of 30-day mortality after PCI. This finding has significant implications in the management of severe coronary artery disease in high-risk severe symptomatic AS patients being considered for transcatheter aortic valve replacement.Background— With the availability of transcatheter aortic valve replacement, management of coronary artery disease in patients with severe aortic stenosis (AS) is posing challenges. Outcomes of percutaneous coronary intervention (PCI) in patients with severe AS and coronary artery disease remain unknown. We sought to compare the short-term outcomes of PCI in patients with and without AS. Methods and Results— From our PCI database, we identified 254 patients with severe AS who underwent PCI between 1998 and 2008. Using propensity matching, we found 508 patients without AS who underwent PCI in the same period. The primary end point of 30-day mortality after PCI was similar in patients with and without severe AS (4.3% [11 of 254] versus 4.7% [24 of 508]; hazard ratio, 0.93; 95% confidence interval, 0.51–1.69; P =0.2). Patients with low ejection fraction (≤30%) and severe AS had a higher 30-day post-PCI mortality compared with those with an ejection fraction >30% (5.4% [7 of 45] versus 1.2% [4 of 209]; P <0.001). In addition, AS patients with high Society of Thoracic Surgeons score (≥10) had a higher 30-day post-PCI mortality than those with a Society of Thoracic Surgeons score <10 (10.4% [10 of 96] versus 0%; P <0.001). Conclusions— PCI can be performed in patients with severe symptomatic AS and coronary artery disease without an increased risk of short-term mortality compared with propensity-matched patients without AS. Patients with ejection fraction ≤30% and Society of Thoracic Surgeons score ≥10% are at a highest risk of 30-day mortality after PCI. This finding has significant implications in the management of severe coronary artery disease in high-risk severe symptomatic AS patients being considered for transcatheter aortic valve replacement. # Clinical Perspective {#article-title-29}

Impact of diabetes on long-term mortality following multivessel percutaneous interventions: an insight into optimal statistical analysis.

BACKGROUND Several studies have demonstrated better long-term outcomes with drug eluting stents (DES) as compared to bare metal stents (BMS) among diabetics with coronary artery disease (CAD). A significant heterogeneity exists with respect to the optimal statistical strategy to analyze stent related data. METHODS We used our percutaneous intervention (PCI) registry to identify all diabetics with CAD, who underwent PCI on two or more vessel territories between 2003 and 2009. Long-term mortality was assessed using the social security death index. Six different analytical strategies were applied. RESULTS A total of 1568 DES and 336 BMS interventions were encountered in 756 diabetics. Considerable differences were observed in the results between the methods applied. Generalized estimating equation (GEE) approach with an autoregressive correlation structure (GEE) was a robust method to account for the cluster structure, since the measurements taken through time on the same person were assumed to be highly correlated, if they were spaced more closely in time. Diabetics undergoing PCI with BMS had a significantly higher long-term mortality as compared to the patients undergoing DES-PCI [Hazard ratio (95% CI): 1.47 (1.04-2.09)]. CONCLUSION There is a great potential for erroneous interpretation of PCI data due to complex spatial and temporal clustering. Use of GEE with autoregressive correlation matrix and robust variance is most optimal to account for the clustered nature of the PCI related data. Using GEE, we observed that there is a 47% (4%-119%) higher hazard for mortality among diabetics undergoing BMS-PCI as compared to diabetics undergoing DES-PCI.

ETIOPATHOGENIC DIFFERENCES IN CORONARY ARTERY DISEASE AND PERIPHERAL ARTERY DISEASE: RESULTS FROM NATIONAL HEALTH AND NUTRITION EXAMINATION SURVEY (NHANES) 1999-2004

Results: In comparison to CAD, a greater proportion of individuals with PAD were females (65% vs 41%), blacks (16% vs 7%) and active smokers (30% vs 24%). After adjustment for demographic and clinical characteristics, patients with PAD had significantly higher serum concentrations of LDL, triglycerides and C-reactive protein (CRP). Among active smokers, the risk of PAD [OR(95%CI):2.82(2.20-3.61)] was observed to be significantly higher than the risk of CAD [OR(95%CI):1.60(1.10-2.34)]. The risk of CAD increased with cotinine levels >0.02ng/mL. However, the risk of PAD increased only with cotinine levels >138 ng/mL. With respect to CRP, the risk of CAD and PAD tended to increase with CRP>0.25mg/dL. However, the risk of PAD was higher than the risk of CAD with increasing CRP levels.

Response to Letter Regarding Article "Percutaneous Coronary Intervention in Patients With Severe Aortic Stenosis: Implications for Transcatheter Aortic Valve Replacement"

We appreciate the interest in our article1 shown by Dr Khawaja and colleagues. We agree that the majority of percutaneous coronary interventions (PCIs) are performed in patients with severe aortic stenosis (AS) who are undergoing transcatheter aortic valve replacement (TAVR) in the context of stable coronary artery disease (CAD) and not acute coronary syndromes. We stratified our data by distinct clinical subgroups based on the indication for PCI and found no difference in the 30-day mortality after PCI among patients with and without AS and with unstable angina (5 of 105 [5%] vs 11 of 185 [6%], respectively; P =0.67), non-ST-elevation myocardial infarction (3 of 48 [6%] vs 7 of 90 [8%], respectively; P =0.74), and ST …

Percutaneous Coronary Intervention in Patients With Severe Aortic StenosisClinical Perspective

Background— With the availability of transcatheter aortic valve replacement, management of coronary artery disease in patients with severe aortic stenosis (AS) is posing challenges. Outcomes of percutaneous coronary intervention (PCI) in patients with severe AS and coronary artery disease remain unknown. We sought to compare the short-term outcomes of PCI in patients with and without AS. Methods and Results— From our PCI database, we identified 254 patients with severe AS who underwent PCI between 1998 and 2008. Using propensity matching, we found 508 patients without AS who underwent PCI in the same period. The primary end point of 30-day mortality after PCI was similar in patients with and without severe AS (4.3% [11 of 254] versus 4.7% [24 of 508]; hazard ratio, 0.93; 95% confidence interval, 0.51–1.69; P=0.2). Patients with low ejection fraction (⩽30%) and severe AS had a higher 30-day post-PCI mortality compared with those with an ejection fraction >30% (5.4% [7 of 45] versus 1.2% [4 of 209]; P<0.001). In addition, AS patients with high Society of Thoracic Surgeons score (≥10) had a higher 30-day post-PCI mortality than those with a Society of Thoracic Surgeons score <10 (10.4% [10 of 96] versus 0%; P<0.001). Conclusions— PCI can be performed in patients with severe symptomatic AS and coronary artery disease without an increased risk of short-term mortality compared with propensity-matched patients without AS. Patients with ejection fraction ⩽30% and Society of Thoracic Surgeons score ≥10% are at a highest risk of 30-day mortality after PCI. This finding has significant implications in the management of severe coronary artery disease in high-risk severe symptomatic AS patients being considered for transcatheter aortic valve replacement.Background— With the availability of transcatheter aortic valve replacement, management of coronary artery disease in patients with severe aortic stenosis (AS) is posing challenges. Outcomes of percutaneous coronary intervention (PCI) in patients with severe AS and coronary artery disease remain unknown. We sought to compare the short-term outcomes of PCI in patients with and without AS. Methods and Results— From our PCI database, we identified 254 patients with severe AS who underwent PCI between 1998 and 2008. Using propensity matching, we found 508 patients without AS who underwent PCI in the same period. The primary end point of 30-day mortality after PCI was similar in patients with and without severe AS (4.3% [11 of 254] versus 4.7% [24 of 508]; hazard ratio, 0.93; 95% confidence interval, 0.51–1.69; P =0.2). Patients with low ejection fraction (≤30%) and severe AS had a higher 30-day post-PCI mortality compared with those with an ejection fraction >30% (5.4% [7 of 45] versus 1.2% [4 of 209]; P <0.001). In addition, AS patients with high Society of Thoracic Surgeons score (≥10) had a higher 30-day post-PCI mortality than those with a Society of Thoracic Surgeons score <10 (10.4% [10 of 96] versus 0%; P <0.001). Conclusions— PCI can be performed in patients with severe symptomatic AS and coronary artery disease without an increased risk of short-term mortality compared with propensity-matched patients without AS. Patients with ejection fraction ≤30% and Society of Thoracic Surgeons score ≥10% are at a highest risk of 30-day mortality after PCI. This finding has significant implications in the management of severe coronary artery disease in high-risk severe symptomatic AS patients being considered for transcatheter aortic valve replacement. # Clinical Perspective {#article-title-29}

Percutaneous Coronary Intervention in Patients With Severe Aortic StenosisClinical Perspective: Implications for Transcatheter Aortic Valve Replacement

Background— With the availability of transcatheter aortic valve replacement, management of coronary artery disease in patients with severe aortic stenosis (AS) is posing challenges. Outcomes of percutaneous coronary intervention (PCI) in patients with severe AS and coronary artery disease remain unknown. We sought to compare the short-term outcomes of PCI in patients with and without AS. Methods and Results— From our PCI database, we identified 254 patients with severe AS who underwent PCI between 1998 and 2008. Using propensity matching, we found 508 patients without AS who underwent PCI in the same period. The primary end point of 30-day mortality after PCI was similar in patients with and without severe AS (4.3% [11 of 254] versus 4.7% [24 of 508]; hazard ratio, 0.93; 95% confidence interval, 0.51–1.69; P=0.2). Patients with low ejection fraction (⩽30%) and severe AS had a higher 30-day post-PCI mortality compared with those with an ejection fraction >30% (5.4% [7 of 45] versus 1.2% [4 of 209]; P<0.001). In addition, AS patients with high Society of Thoracic Surgeons score (≥10) had a higher 30-day post-PCI mortality than those with a Society of Thoracic Surgeons score <10 (10.4% [10 of 96] versus 0%; P<0.001). Conclusions— PCI can be performed in patients with severe symptomatic AS and coronary artery disease without an increased risk of short-term mortality compared with propensity-matched patients without AS. Patients with ejection fraction ⩽30% and Society of Thoracic Surgeons score ≥10% are at a highest risk of 30-day mortality after PCI. This finding has significant implications in the management of severe coronary artery disease in high-risk severe symptomatic AS patients being considered for transcatheter aortic valve replacement.Background— With the availability of transcatheter aortic valve replacement, management of coronary artery disease in patients with severe aortic stenosis (AS) is posing challenges. Outcomes of percutaneous coronary intervention (PCI) in patients with severe AS and coronary artery disease remain unknown. We sought to compare the short-term outcomes of PCI in patients with and without AS. Methods and Results— From our PCI database, we identified 254 patients with severe AS who underwent PCI between 1998 and 2008. Using propensity matching, we found 508 patients without AS who underwent PCI in the same period. The primary end point of 30-day mortality after PCI was similar in patients with and without severe AS (4.3% [11 of 254] versus 4.7% [24 of 508]; hazard ratio, 0.93; 95% confidence interval, 0.51–1.69; P =0.2). Patients with low ejection fraction (≤30%) and severe AS had a higher 30-day post-PCI mortality compared with those with an ejection fraction >30% (5.4% [7 of 45] versus 1.2% [4 of 209]; P <0.001). In addition, AS patients with high Society of Thoracic Surgeons score (≥10) had a higher 30-day post-PCI mortality than those with a Society of Thoracic Surgeons score <10 (10.4% [10 of 96] versus 0%; P <0.001). Conclusions— PCI can be performed in patients with severe symptomatic AS and coronary artery disease without an increased risk of short-term mortality compared with propensity-matched patients without AS. Patients with ejection fraction ≤30% and Society of Thoracic Surgeons score ≥10% are at a highest risk of 30-day mortality after PCI. This finding has significant implications in the management of severe coronary artery disease in high-risk severe symptomatic AS patients being considered for transcatheter aortic valve replacement. # Clinical Perspective {#article-title-29}

Comparison of outcomes of unprotected left main versus multivessel coronary artery interventions.

Left main coronary artery (LMCA) percutaneous coronary intervention (PCI) has emerged as an appealing alternative to bypass surgery for significant LMCA disease, especially in high-risk candidates. PCI for unprotected LMCA stenosis is currently designated a class IIb indication. Direct comparisons between unprotected LMCA PCI and multivessel PCI are lacking. We aimed to determine the incremental risk associated with unprotected LMCA PCI compared to multivessel PCI. We queried the Cleveland Clinic PCI database to identify patients who underwent unprotected LMCA PCI from 2003 through 2009 and compared these to patients undergoing multivessel PCI in the same period. Patients undergoing PCI for acute myocardial infarction were excluded. Mortality was derived using the Social Security Death Index. Short-term (≤30-day) mortality rates in the LMCA PCI group (n = 468, 1.9%) were similar to the death rate in the multivessel PCI group (n = 1,973, 1.3%, p = 0.3). There was no significant difference in adjusted mortality between the 2 study groups. Stratifying LMCA PCI by the number of concomitant vessel territories treated, there was no significant difference in mortality in any LMCA PCI category (LMCA only, LMCA + 1-vessel PCI, LMCA + multivessel PCI) compared to multivessel PCI. In conclusion, there was comparable short-term and long-term mortality in the LMCA PCI and multivessel PCI groups. LMCA stenting did not appear to incur incremental risk compared to multivessel PCI.