Waleed T. Kayani

Comparison by Meta-Analysis of Mortality After Isolated Coronary Artery Bypass Grafting in Women Versus Men

Short- and long-term mortality in women who undergo coronary artery bypass grafting (CABG) has been evaluated in multiple studies with conflicting results. The investigators conducted a meta-analysis of all existing studies to evaluate the impact of female gender on mortality in patients who undergo isolated CABG. A comprehensive search of studies published through May 31, 2012 identified 20 studies comparing men and women who underwent isolated CABG. All-cause mortality was evaluated at short-term (postoperative period and/or at 30 days), midterm (1-year), and long-term (5-year) follow-up. Odds ratios (ORs) and 95% confidence interval (CIs) were calculated using a random-effects model. A total of 966,492 patients (688,709 men [71%], 277,783 women [29%]) were included in this meta-analysis. Women were more likely to be older; had significantly greater co-morbidities, including hypertension, diabetes mellitus, hyperlipidemia, unstable angina, congestive heart failure, and peripheral vascular disease; and were more likely to undergo urgent CABG (51% vs 44%, p <0.01). Short-term mortality (OR 1.77, 95% CI 1.67 to 1.88) was significantly higher in women. At midterm and long-term follow-up, mortality remained high in women compared with men. Women remained at increased risk for short-term mortality in 2 subgroup analyses including prospective studies (n = 41,500, OR 1.83, 95% CI 1.59 to 2.12) and propensity score-matched studies (n = 11,522, OR 1.36, 95% CI 1.04 to 1.78). In conclusion, women who underwent isolated CABG experienced higher mortality at short-term, midterm, and long-term follow-up compared with men. Mortality remained independently associated with female gender despite propensity score-matched analysis of outcomes.

Outcomes of Preoperative Angiotensin-Converting Enzyme Inhibitor Therapy in Patients Undergoing Isolated Coronary Artery Bypass Grafting

The association between preoperative use of angiotensin-converting enzyme (ACE) inhibitors and outcomes after coronary artery bypass grafting (CABG) remain controversial. Our aim was to study in-hospital outcomes after isolated CABG in patients on preoperative ACE inhibitors. A retrospective analysis of 8,889 patients who underwent isolated CABG from 2000 through 2011 was conducted. The primary outcome of interest was the incidence of major adverse events (MAEs) defined as a composite of mortality, postoperative renal dysfunction, myocardial infarction, stroke, and atrial fibrillation during index hospitalization. The secondary outcome was the incidence of individual outcomes included in MAEs. Logistic regression analyses were performed. Of 8,889 patients, 3,983 (45%) were on preoperative ACE inhibitors and 4,906 (55%) were not. Overall incidence of MAEs was 38.1% (n = 1,518) in the ACE inhibitor group compared to 33.6% (n = 1,649) in the no-ACE inhibitor group. Preoperative use of ACE inhibitors was independently associated with MAEs (odds ratio 1.13, 95% confidence interval 1.03 to 1.24), most of which was driven by a statistically significant increase in postoperative renal dysfunction (odds ratio 1.18, 95% confidence interval 1.03 to 1.36) and atrial fibrillation (odds ratio 1.15, 95% confidence interval 1.05 to 1.27). In-hospital mortality, postoperative myocardial infarction, and stroke were not significantly associated with preoperative ACE inhibitor use. Analyses performed after excluding patients with low ejection fractions yielded similar results. In conclusion, preoperative ACE inhibitor use was associated with an increased risk of MAEs after CABG, in particular postoperative renal dysfunction and atrial fibrillation.

Association between statins and infections after coronary artery bypass grafting

BACKGROUND We determined whether pre-operative statin therapy is associated with a decrease in the incidence of infections after coronary artery bypass grafting (CABG). METHODS A retrospective cohort study of 6253 patients undergoing isolated CABG, from the Texas Heart Institute Database from January 1, 2000 to December 31, 2010 (3869 receiving statins and 2384 not receiving statins) was conducted. Primary outcome was the development of any postoperative infection (composite of deep-sternal wound infection, leg harvest-site infection, pneumonia, or sepsis) after CABG. Secondary outcome was the association between pre-operative statin use and individual incidence of each aforementioned infection. Logistic regression analyses were performed. RESULTS Incidence of any postoperative infection in patients who received statins pre-operatively was 6.5% compared to 8.3% in patients who did not receive statins. Pre-operative statin therapy was associated with a significant reduction in the primary outcome (odds ratio (OR) 0.74, 95% confidence interval (CI) 0.60-0.90) in adjusted models. Among individual secondary outcomes, pre-operative statin therapy was associated with a reduced incidence of sternal wound infections (2.5% vs. 3.2%, OR 0.6, 95% CI 0.5-0.8) and leg harvest site infections (0.6% vs. 1.3%, OR 0.46, 95% CI 0.2-0.8). Pre-operative statin therapy was not associated with a reduced incidence of pneumonia or sepsis. CONCLUSION Pre-operative statin use is associated with a decrease in overall incidence of post-operative infections after CABG. We propose immunomodulatory effects of statins leading to a dampening of inflammatory cascade as the cause of our findings.

Comparison of segmental wall motion abnormalities on echocardiography in patients with anteroseptal versus extensive anterior wall ST-segment elevation myocardial infarction.

OBJECTIVE Acute anteroseptal ST-segment elevation (STE) myocardial infarction (AS-STEMI), defined as STE limited to leads V1 to V3, has historically been associated with a smaller infarct size than extensive anterior STEMI (EA-STEMI), in which STE extends to leads V4 to V6. We compared the differences in global and regional wall motion by transthoracic echocardiography between patients with AS-STEMI and EA-STEMI. METHODS Patients who presented with anterior STEMI and underwent primary percutaneous coronary intervention between January 2008 and March 2011 were included. For each subject, a transthoracic echocardiogram that was performed within 24 hours of admission was interpreted by an independent investigator blinded to the patients electrocardiographic data. RESULTS Of the 65 subjects who met our inclusion criteria, 30 had AS-STEMI and 35 had EA-STEMI. No differences were observed between groups in baseline characteristics or the mean number of hypokinetic, akinetic, and dyskinetic segments. Apical inferior segment dysfunction occurred more often in patients with EA-STEMI than in patients with AS-ASTEMI (71.4% vs 43.3%; P=.04). Distribution and extent of wall motion abnormalities were similar between patients with AS-STEMI and those with EA-STEMI. CONCLUSION The term AS-STEMI may be misleading, as it implies that only the anteroseptal segments are involved. We show that regional dysfunction in patients with AS-STEMI extends beyond the anteroseptal region.

Meta-Analysis of Comparison of 5-Year Outcomes of Percutaneous Coronary Intervention Versus Coronary Artery Bypass Grafting in Patients With Unprotected Left Main Coronary Artery in the Era of Drug-eluting Stents.

Patients with unprotected left main coronary artery (ULMCA) disease are increasingly being treated with percutaneous coronary intervention (PCI) using drug-eluting stents (DES), but long-term outcomes comparing PCI with coronary artery bypass grafting (CABG) remain limited. We performed aggregate data meta-analyses of clinical outcomes (all-cause death, nonfatal myocardial infarction, stroke, repeat revascularization, cardiac death, and major adverse cardiac and cerebrovascular events) in studies comparing 5-year outcomes of PCI with DES versus CABG in patients with ULMCA disease. A comprehensive literature search (January 1, 2003 to December 10, 2016) identified 9 studies (6,637 patients). Effect size for individual clinical outcomes was estimated using odds ratio (OR) with 95% confidence intervals (CI) using a random effects model. At 5 years, PCI with DES was associated with equivalent cardiac (OR 0.95, 95% CI 0.62 to 1.46) and all-cause mortality (OR 0.98, 95% CI 0.72 to 1.33), lower rates of stroke (OR 0.50, 95% CI 0.30 to 0.84), and higher rates of repeat revascularization (OR 2.52, 95% CI 1.63 to 3.91); compared with CABG, major adverse cardiac and cerebrovascular events showed a trend favoring CABG but did not reach statistical significance (OR 1.19, 95% CI 0.93 to 1.54). In conclusion, for ULMCA disease, PCI can be considered as a comparably effective and yet less invasive alternative to CABG given the comparable long-term mortality and lower incidences of stroke.

Coronary Artery Disease Performance Measures and Statin Use in Patients With Recent Percutaneous Coronary Intervention or Recent Coronary Artery Bypass Grafting (from the NCDR PINNACLE Registry)

The association between coronary revascularization strategy (percutaneous coronary intervention [PCI] or coronary artery bypass grafting [CABG]) and compliance with coronary artery disease (CAD) performance measures is not well studied. Our analysis studied patients enrolled in the Practice Innovation and Clinical Excellence registry, who underwent coronary revascularization using PCI or CABG in the 12 months before their most recent outpatient visit in 2011. We compared the attainment of CAD performance measures and statin use in eligible patients with PCI and CABG using hierarchical logistic regression models. Our study cohort consisted of 112,969 patients (80,753 with PCI and 32,216 with CABG). After adjustment for site and patient characteristics, performance measure compliance for tobacco use query (odds ratio [OR] 0.80; 95% confidence interval [CI] 0.76 to 0.86), antiplatelet therapy (OR 0.9; 95% CI 0.86 to 0.94) and angiotensin-converting enzyme inhibitor/angiotensin receptor blocker therapy (OR 0.89; 95% CI 0.84 to 0.94) was lower in CABG compared with patients with PCI. Patients who underwent recent CABG had higher rates of β-blocker (OR 1.25; 95% CI 1.16 to 1.33) and statin treatment (OR 1.37; 95% CI 1.31 to 1.43) compared with patients with PCI. Of the 79 practice sites, 15 (19%) had ≥75% of their patients with CAD (CABG or PCI) meeting 75% to 100% of all eligible CAD performance measures. In conclusion, gaps persist in compliance with specific CAD performance measures in patients with recent PCI or CABG, and 1 in 5 practices had ≥75% compliance of eligible CAD performance measures in the most of their patients.

Outcomes of beta blocker use in cocaine-associated chest pain: a meta-analysis

Objectives Beta blockers (β-blockers) remain a standard therapy in the early treatment of acute coronary syndromes. However, β-blocker therapy in patients with cocaine-associated chest pain (CACP) continues to be an area of debate due to the potential risk of unopposed α-adrenergic stimulation and coronary vasospasm. Therefore, we performed a systematic review and meta-analysis of available studies to compare outcomes of β-blocker versus no β-blocker use among patients with CACP. Methods We searched the MEDLINE and EMBASE databases through September 2016 using the keywords ‘beta blocker’, ‘cocaine’ and commonly used β-blockers (‘atenolol’, ‘bisoprolol’, ‘carvedilol’, ‘esmolol’, ‘metoprolol’ and ‘propranolol’) to identify studies evaluating β-blocker use among patients with CACP. We specifically focused on studies comparing outcomes between β-blocker versus no β-blocker usage in patients with CACP. Studies without a comparison between β-blocker and no β-blocker use were excluded. Outcomes of interest included non-fatal myocardial infarction (MI) and all-cause mortality. Quantitative data synthesis was performed using a random-effects model and heterogeneity was assessed using Q and I2statistics. Results A total of five studies evaluating 1794 subjects were included. Overall, there was no significant difference on MI in patients with CACP on β-blocker versus no β-blocker (OR 1.36, 95% CI 0.68 to 2.75; p=0.39). Similarly, there was no significant difference in all-cause mortality in patients on β-blocker versus no β-blocker (OR 0.68, 95% CI 0.26 to 1.79; p=0.43). Conclusions In patients presenting with acute chest pain and underlying cocaine, β-blocker use does not appear to be associated with an increased risk of MI or all-cause mortality.

Outcomes in culprit only versus multivessel percutaneous coronary intervention in ST elevation myocardial infarction during index procedure

Aims: Multivessel disease seen in 40 65% of STEMI patients is associated with higher mortality. ACC/AHA guidelines do not give clear indications regarding revascularization of non-infarct related arteries in the absence of cardiogenic shock while ESC/EACTS guidelines provide a class 2b recommendation for multivessel PCI in the primary intervention in select patients. This meta-analysis aims to evaluate the role of multivessel versus culprit only percutaneous intervention (PCI) in STEMI with multivessel disease. Methods and results: Data from 12 studies enrolling 32,548 patients was examined. Multivessel PCI was defined as PCI of culprit and non-culprit lesions during the index procedure while culprit only PCI was defined as PCI of the infarct related vessel. In-hospital all-cause mortality (OR 0.59, CI 0.36 0.97) and 30 day MACE (OR 0.43, CI 0.19-0.99) favored culprit vessel only PCI compared to multivessel PCI, but this did not remain significantly lower at longer follow-up. The culprit only group experienced a lower rate of stent thrombosis (OR 0.41, CI 0.21 -0.78). At later follow-up, multivessel PCI was associated with lower cardiac death at 12-30 months (OR 2.58, CI 1.22 5.42) and lower rates of repeat revascularization at 2 – 2.5 years (OR 3.77, CI 2.26, 6.27). Conclusion: In conclusion, this meta-analysis demonstrated lower in-hospital all-cause mortality and 30-day MACE events and higher repeat revascularization with culprit only PCI. However, multi-vessel PCI during the index procedure was associated with a lower risk of cardiac death at 12-30 months. Either approach is however safe as evidenced by comparable rates of all cause death, MI, stroke, MACE events, major bleeding or vascular complications at 12 months follow-up. A significant reduction in repeat revascularization and cardiac at later follow-up was seen in patients who underwent multivessel revascularization. Correspondence to: Wilbert S. Aronow, MD, FACC, FAHA, Professor of Medicine, Department of Medicine, Division of Cardiology, New York Medical College, Valhalla, New York, USA, Tel: (914) 493-5311, Fax: (914)-235-6274, E-mail: wsaronow@aol.com

IMPACT OF FEMALE GENDER ON MORTALITY AFTER ISOLATED CORONARY ARTERY BYPASS GRAFTING

Short & long term mortality in women undergoing CABG has been evaluated in multiple studies with conflicting results. We conducted meta–analysis of existing literature to evaluate the impact of female sex on mortality in patients undergoing isolated CABG. A comprehensive literature search (PubMed