Yu Jie Zhou

Meta-analysis of the combination of warfarin and dual antiplatelet therapy after coronary stenting in patients with indications for chronic oral anticoagulation

BACKGROUND The optimal antithrombotic strategy for patients with chronic oral anticoagulation undergoing coronary stenting is unknown. Our study conducted a meta-analysis of 9 previous trials comparing the safety and efficacy of triple antithrombotic regimen (including warfarin, aspirin and clopidogrel) to non-triple antithrombotic regimens in those patients. METHODS Two investigators independently searched Pubmed, Ovid and Elsevier databases for all reported studies, and yielded 9 (of 242 potentially relevant) articles, published before July 2009, enrolling 5181 patients, follow-up period ranging from 1 month to 18 months. Two coauthors independently recorded the data regarding interventions and the occurrence of major bleeding, stroke, myocardial infarction and death. RESULTS Patients with triple antithrombotic regimen had significant reduction in ischemic stroke (odds ratio [OR] is 0.29, 95% confidence interval [CI] is from 0.15 to 0.58; and P=0.0004) as compared with dual antiplatelet therapy. While there was a two-fold increased risk of major bleeding associated with triple antithrombotic regime (OR 2.00, 95% CI 1.41 to 2.83; and P<0.0001). The overall incidence of death (OR 1.20, 95% CI 0.63 to 2.27, and P=0.56) and myocardial infarction (OR 0.84, 95% CI 0.57 to 1.23; and P=0.38) was comparable between the two regimens. CONCLUSION Our study confirmed the cardiovascular benefits of triple antithrombotic regimen by reducing ischemic stroke risk, but also demonstrated its increased risk of major bleeding. It poses imperative demands for future prospective randomized studies to define the optimal antithrombotic regimen in patients requiring chronic anticoagulation undergoing coronary stenting.

Association of body mass index with mortality and cardiovascular events for patients with coronary artery disease: a systematic review and meta-analysis

Objectives The association between obesity and prognosis in patients with coronary artery disease (CAD) remains uncertain. We undertook a meta-analysis for the effects of body mass index (BMI) on mortality and cardiovascular events in these patients. Methods We identified studies that provided risk estimates for mortality or cardiovascular events on the basis of BMI in patients with CAD. Summary estimates of relative risks were obtained for five BMI groups: underweight, normal-weight, overweight, obese and grade II/III obese. Mortality was analysed separately as short-term (<6 months) and long-term (≥6 months). Results Data from 89 studies with 1 300 794 patients were included. Mean follow-up of long-term estimates was 3.2 years. Using normal-weight as the reference, underweight was associated with higher risk of short-term mortality (2.24 (1.85 to 2.72)) and long-term mortality (1.70 (1.56 to 1.86)), overweight and obesity were both associated with lower risk of short-term mortality (0.69 (0.64 to 0.75); 0.68 (0.61 to 0.75)) and long-term mortality (0.78 (0.74 to 0.82); 0.79 (0.73 to 0.85)), but the long-term benefit of obesity disappeared after 5 years of follow-up (0.99 (0.91 to 1.08)). Grade II/III obesity was associated with lower risk of mortality in the short term (0.76 (0.62 to 0.91)) but higher risk after 5 years of follow-up (1.25 (1.14 to 1.38)). The similar J-shaped pattern was also seen for cardiovascular mortality and across different treatment strategies. Meta-regression found an attenuation of the inverse association between BMI and risk of mortality over longer follow-up. Conclusions Our data support a J-shaped relationship between mortality and BMI in patients with CAD. The limitation of current literature warrants better design of future studies.

Obesity and cardiovascular thrombotic events in patients undergoing percutaneous coronary intervention with drug-eluting stents

Background: Previous studies have reported conflicting findings regarding the relation of body mass index (BMI) to outcomes following percutaneous coronary interventions (PCI). No study to date has directly examined the effect of obesity on cardiovascular thrombotic events after stent implantation. Objective: To evaluate the effect of obesity on cardiovascular thrombotic events in patients undergoing PCI with drug-eluting stents. Methods: We studied 4972 patients between January 2004 and December 2006. Patients were divided into three groups according to body mass index: normal (BMI <24.9 kg/m2, n = 1284), overweight (BMI 25–29.9 kg/m2, n = 2475) and obese (BMI ⩾30 kg/m2, n = 1213). Median follow-up was 26 (interquartile range 20–33) months. Results: Composite cardiovascular thrombotic events, including cardiac death and non-fatal myocardial infarction, were significantly higher in obese patients (5.9%) than in normal (3.2%) and overweight (3.8%) patients (p = 0.001). The incidence of definite or probable stent thrombosis steadily increased with increasing body mass index (0.9% vs 1.0% vs 1.9% in normal, overweight and obese patients, respectively; p = 0.029). Multivariate analyses showed that obesity was an independent predictor of 3-year composite thrombotic events (hazard ratio 1.86; 95% confidence interval 1.25 to 2.75; p = 0.003) and definite or probable stent thrombosis (2.17; 1.04 to 4.55; p = 0.040). Conclusions: Obese patients have a higher risk for long-term cardiovascular thrombotic events following PCI with drug-eluting stents than patients with normal weight.

C-reactive protein and the risk of contrast-induced acute kidney injury in patients undergoing percutaneous coronary intervention.

Background: The relationship between preprocedural C-reactive protein (CRP) levels and the incidence of contrast-induced acute kidney injury (CI-AKI) is unknown. Methods: Documents of 7,310 consecutive patients undergoing percutaneous coronary intervention (PCI) were screened. Patients with acute myocardial infarction, cardiogenic shock, concomitant inflammatory conditions or undergoing CABG within 48 h were excluded due to potential confounding effects. Results: A total of 4,522 patients were valid for analysis. The median follow-up was 26 months (interquartile range 20–33 months). According to preprocedural CRP values, patients were divided into 3 groups: group 1: CRP <1.0 mg/l (n = 1,523); group 2: 1.0 mg/l ≤ CRP ≤ 3.0 mg/l (n = 1,626); group 3: CRP >3.0 mg/l (n = 1,373). Patients with higher preprocedural CRP levels were associated with a significantly increased rate of CI-AKI (10.6 vs. 14.9 vs. 23.5%, p < 0.0001). After adjustment for baseline covariates, CRP level was still an independent predictor for the incidence of CI-AKI, either as a continuous variable or a categorical variable. Patients with higher CRP values had a significantly higher rate of all-cause mortality and myocardial infarction during follow-up. Conclusion: Elevated preprocedural CRP is associated with an increased risk for CI-AKI in patients undergoing PCI. Preprocedural risk stratification with CRP as an adjunct to established clinical risk factors might be useful.

Effect of Obesity on Repeat Revascularization in Patients Undergoing Percutaneous Coronary Intervention With Drug‐Eluting Stents

Obesity is a major risk factor for developing coronary artery disease. The impact of obesity on prognosis among those with established coronary disease is less clear. The objective of this study was to evaluate the effect of obesity on repeat revascularization in patients undergoing percutaneous coronary intervention (PCI) with drug‐eluting stents (DES). We examined 6,083 patients who were divided into three groups according to BMI: normal (BMI 18.5–24.9 kg/m2, n = 1,592); overweight (BMI 25–29.9 kg/m2, n = 3,026) and obese (BMI >30 kg/m2, n = 1,465). The follow‐up focused on clinical‐driven repeat revascularization, including target lesion revascularization (TLR) and nonTLR. Median follow‐up was 26 months (interquartile range 20–32). There was no significant difference in the incidence of TLR among normal, overweight, and obese patients (6.3% vs. 6.1% vs. 7.1%; P = 0.423). In contrast, the incidence of nonTLR was significantly higher in obese patients compared with normal and overweight (8.4% vs. 6.0% vs. 5.8%, P = 0.003). Multivariate analysis showed that obesity was an independent predictor of nonTLR during follow‐up (hazard ratio = 1.39; 95% confidence interval = 1.06–1.83; P = 0.019), along with diabetes and hypercholesterolemia. Concomitant use of statins was independently associated with decreased risk of nonTLR (hazard ratio = 0.75; 95% confidence interval = 0.62–0.92; P = 0.005). In conclusion, among patients undergoing PCI with DES, obesity was not associated with TLR, but was associated with a higher risk of nonTLR.

Rationale and design of the RT-AF study: Combination of rivaroxaban and ticagrelor in patients with atrial fibrillation and coronary artery disease undergoing percutaneous coronary intervention

OBJECTIVE Optimal antithrombotic strategy for patients with concomitant coronary artery disease and atrial fibrillation (AF) undergoing percutaneous coronary intervention (PCI) is still controversial, and the role of novel antithrombotic agents has nerve been tested. Therefore, the aim of this study is to evaluate and overall safety and efficacy profile of the combination of rivaroxaban and ticagrelor in this particular population. DESIGN The RT-AF study is an open-label, randomized, active-controlled, multicenter clinical trial with up to 420 subjects enrolled in 5 centers. Eligible patients, who have a history or new onset paroxysmal, persistent, or permanent non-valvular AF, referred to the study centers with indications for PCI will be randomly assigned to receive triple therapy (including warfarin, clopidogrel and aspirin) or dual therapy (rivaroxaban and ticagrelor). All subjects will have clinical follow-up at discharge, at 30 days, 6 months and 12 months. The primary end point is major or clinically relevant non-major bleeding events at 12 months. The major secondary end point is the composite efficacy outcome of death, myocardial infarction, stent thrombosis and ischemic stroke. CONCLUSION The study will be sufficiently powered to provide data primarily regarding the safety of dual therapy with rivaroxaban and ticagrelor over the traditional triple therapy in patients with AF undergoing PCI at 12 months. It will also provide important information regarding the efficacy of the two different antithrombotic regimens. (ClinicalTrials.gov identifier: NCT02334254).

The Effect of Intravenous Vitamin C Infusion on Periprocedural Myocardial Injury for Patients Undergoing Elective Percutaneous Coronary Intervention

BACKGROUND This small study has determined the effect of vitamin C on myocardial reperfusion in patients undergoing elective percutaneous coronary intervention (PCI). This study was to explore whether antioxidant vitamin C infusion before the procedure is able to affect the incidence of periprocedural myocardial injury (PMI) in patients undergoing PCI. METHODS In this prospective single-centre randomized study, 532 patients were randomized into 2 groups: the vitamin C group, which received a 3-g vitamin C infusion within 6 hours before PCI, and a control group, which received normal saline. The primary end point was the troponin I-defined PMI, and the second end point was the creatine kinase (CK)-MB-defined PMI. Separate analyses using both end points were performed. PMI was defined as an elevation of cardiac biomarker values (CK-MB or troponin I) > 5 times the upper limit of normal (ULN), alone or associated with chest pain or ST-segment or T-wave changes. RESULTS After PCI, the incidence of PMI was reduced, whether defined by troponin or by CK-MB, compared with the control group (troponin I, 10.9% vs 18.4%; P = 0.016; CK-MB, 4.2% vs 8.6%; P = 0.035). Logistic multivariate analysis showed that preprocedure use of vitamin C is an independent predictor of PMI either defined by troponin I (odds ratio [OR], 0.56; 95% confidence interval [CI], 0.33-0.97; P = 0.037) or by CK-MB (OR, 0.37; 95% CI, 0.14-0.99; P = 0.048). CONCLUSIONS In patients undergoing elective PCI, preprocedure intravenous treatment with vitamin C is associated with less myocardial injury.

Association of depression with adverse cardiovascular events after percutaneous coronary intervention.

ObjectiveThe aim of this study was to investigate the impact of depression on the clinical outcomes of patients with coronary artery disease undergoing percutaneous coronary intervention (PCI). MethodsA total of 400 patients treated with PCI were assessed using the Mini-International Neuropsychiatric Interview 1 day before and 2 weeks after the procedure. All patients were followed up for 3 years after the procedure. The primary endpoint was a major adverse cardiovascular event (MACE) including mortality, nonfatal myocardial infarction, or repeat revascularization. ResultsDepression was present in 38.5% (n=154) of patients after the procedure, which was significantly higher than that before the procedure (25.5%, P<0.001). Patients with postprocedure depression had a higher rate of MACE (27.3 vs. 13.0%, P<0.001), mortality (5.8 vs. 2.0%, P=0.044), and repeat revascularization (13.0 vs. 6.5%, P=0.027) compared with patients without depression during the 3 years of follow-up. After adjustment for other factors that affect cardiovascular outcomes, postprocedure depression was seen to be an independent predictor of 3-year MACE [hazard ratio: 2.51, 95% confidence interval (CI): 1.57–4.02, P<0.001], mortality (3.60, 95% CI: 1.16–11.22, P=0.027), and repeat revascularization (hazard ratio: 2.22, 95% CI: 1.09–4.51, P=0.029). ConclusionDepression is common among patients treated with PCI. Postprocedure depression is an independent predictor of 3-year MACE, mortality, and repeat revascularization.

Contemporary Management and Attainment of Cholesterol Targets for Patients with Dyslipidemia in China

Aims It is well-established that lipid disorder is an important cardiovascular risk factor, and failure to reach optimal lipid levels significantly contributes to the residual cardiovascular risks. However, limited information is available on the management and the attainment of recommended cholesterol targets in real-world practice in China. Methods and Results A nationally representative sample of 12,040 patients with dyslipidemia from 19 provinces and 84 hospitals across China were consecutively enrolled in this survey. Risk stratification and individual cholesterol target was established for all participants. This survey identified a high-risk cohort, with over 50% of patients had hypertension, 37.5% had coronary artery disease, and more than 30% had peripheral artery disease. Thirty-nine percent of all participants received lipid lowering medications. And the majority of them (94.5%) had statins (42.5% with atorvastatin, 29.0% with simvastatin, and 15.2% with rosuvastatin). However, the overall attainment for low-density lipoprotein cholesterol (LDL-C) target is low (25.8%), especially, in female (22.2%), and in patients with increased body mass index (BMI) (38.3% for BMI<18.5, 28.1% for BMI 18.5–24.9, 26.0% for BMI 25.0–29.9, and 17.4% for BMI≥30, P<0.0001). Subgroup analysis also showed the attainment is significantly lower in patients who were stratified into high (19.9%) and very high (21.1%) risk category. In logistic regression analysis, eight factors (BMI, gender, coronary artery disease, systolic and diastolic blood pressure, hypertension, family history of premature coronary artery disease and current smoking) were identified as independent predictors of LDL-C attainment. Conclusions Despite the proven benefits of lipid-lowering therapies, current management of dyslipidemia continues to be unsatisfied. A considerable proportion of patients failed to achieve guideline-recommended targets in China, and this apparent treatment gap was more pronounced among patients with increased BMI, higher risk stratification and women.

Impact of Chronic Obstructive Pulmonary Diseases on Outcomes and Hospital Days After Percutaneous Coronary Intervention

Chronic obstructive pulmonary disease (COPD) is common in patients undergoing percutaneous coronary intervention (PCI), but the impact of COPD on outcomes after PCI has received limited attention. Consecutive patients with coronary heart disease (n = 5155) undergoing PCI were enrolled in this study; 645 patients (73% men) aged 68.4 ± 13.2 years had COPD and 4510 patients (71% men) aged 64.7 ± 12.1 years did not. During the in-hospital period after PCI, the patients with COPD experienced a significantly higher incidence of angina (P < .001), arrhythmias (P < .001), and composite major adverse cardiac events (MACEs; P < .001) and longer hospital stay (P < .001) than those without COPD. Additionally, severity of COPD (measured by pulmonary function tests) was associated with increased composite MACE (P < .001) and hospital stay (P < .001) after PCI. In conclusion, COPD is associated with significantly increased composite MACE and hospital stay in patients after PCI. Increasing severity of COPD is associated with increased composite MACE and hospital stay after PCI.