The Prognostic Value of Cardiac Troponin I in Patients with or without Three-Vessel Disease Undergoing Complete Percutaneous Coronary Intervention.
ABSTRACT: Postprocedural cardiac troponin I (cTnI) elevation commonly occurs in patients undergoing percutaneous coronary intervention (PCI); however, its prognostic value remains controversial. This study aimed to investigate the prognostic value of peak postprocedural cTnI in cardiac patients with or without three-vessel disease (TVD) undergoing complete PCI. A total of 1237 consecutive patients (77% males, mean age 58 ± 10 years) with normal baseline cTnI levels were enrolled, 439 patients (77% males, 59 ± 10 years) with TVD, and 798 patients (77% males, 57 ± 10 years) with single- or double-vessel disease (non-TVD). The primary outcome was the occurrence of major adverse cardiovascular events (MACE), defined as a composite of non-fatal MI, non-fatal stroke, unplanned revascularization, re-hospitalization due to heart failure or severe arrhythmias, and all-cause death. During the median follow-up of 5.3 years, a total of 169 patients (13.7%) developed MACE, including 73 (16.6%) in the TVD group and 96 (12.0%) in the non-TVD group (p = 0.024). After adjustment, the multivariate Cox analysis showed that hypertension (HR 1.50; 95% CI: 1.01-2.20; p = 0.042), TVD (HR 1.44; 95% CI: 1.03-2.02; p = 0.033), and cTnI ≥ 70× URL (HR 2.47; 95% CI: 1.28-4.78, p = 0.007) were independently associated with increased MACE during long-term follow-up. Further subgroup analyses showed that cTnI ≥ 70× URL was an independent predictor of MACE in TVD patients (HR 3.32, 95% CI: 1.51-7.34, p = 0.003), but not in non-TVD patients (HR 1.01, 95%CI: 0.24-4.32, p = 0.991). In conclusion, elevation of post-PCI cTnI ≥ 70× URL is independently associated with a high risk of MACE during long-term follow-up in patients with TVD, but not in those with non-TVD.
Project description:Recent studies and guidelines have indicated that lipoprotein(a) [Lp(a)]was an independent risk factor of arteriosclerotic cardiovascular disease (ASCVD). This study aimed to determine the relationship between serum Lp(a) levels and the risk of periprocedural myocardial injury following percutaneous coronary intervention (PCI) in coronary heartdisease (CHD) patients. This study enrolled 528 nonacute myocardial infarction (AMI) coronary heart disease (CHD) patients who successfully underwent PCI. Fasting serum lipids including Lp(a) were tested before PCI. High-sensitivity cardiac troponin I (hs-cTnI) was tested before PCI and 24 h after PCI. Univariate and multivariate logistic regression analyses were used to determine the relationship between preprocedural Lp(a) levels and postprocedural cTnI elevation from 1?×?upper limit of normal (ULN) to 70?×?ULN. As a continuous variable, multivariate analyses adjusting for conventional covariates and other serum lipids revealed that increased Lp(a) levels were independently associated with the risk of elevated postprocedural cTnI values above 1?×?ULN (odds ratio [OR] per log-unit higher: 1.31, 95% confidence interval [CI]: 1.02-1.68, P?=?0.033], 5?×?ULN (OR: 1.25, 95%CI: 1.02-1.53, P?=?0.032), 10?×?ULN (OR: 1.48, 95%CI: 1.18-1.86, P?=?0.001) and 15?×?ULN (OR: 1.28, 95%CI: 1.01-1.61, P?=?0.038). As a categorical variable, Lp(a)?>?300 mg/L was an independent risk factor of postproceduralc TnI?1?×?ULN (OR 2.17, 95%CI 1.12-4.21, P?=?0.022), ?5?×?ULN (OR 1.82, 95%CI 1.12-2.97, P?=?0.017) and ?10?×?ULN (OR 2.17, 95%CI 1.33-3.54, P?=?0.002). Therefore, it could be concluded that elevated preprocedural Lp(a) levels were associated with the risk of PCI-related myocardial injury in non-AMI CHD patients.
Project description:<h4>Background</h4>The prognostic implication of statin in tolerance (SI) in those with stable CAD remains unclear. We hypothesized that SI is of higher prognostic significance in stable CAD patients with elevated high-sensitive cardiac troponin I (hs-cTnI).<h4>Methods</h4>A total of 952 stable CAD patients from the prospective Hong Kong CAD study who had complete clinical data, biomarker measurements and who were prescribed statin therapy were studied.<h4>Results</h4>We identified 13 (1.4%) and 125 (13.1%) patients with complete and partial SI, respectively. At baseline, patients with SI were more likely to have diabetes mellitus and a higher hs-cTnI level, but no difference in LDL-C level compared with those without SI. After 51?months of follow-up, patients with SI had a higher mean LDL-C level than those without SI. A total of 148 (15.5%) patients developed major adverse cardiovascular events (MACEs). Both SI (HR 1.52, 95% CI 1.06-2.19, P =?0.02) and elevated hs-cTnI (HR 3.18, 95% CI 2.07-4.89, P <?0.01) were independent predictors of a MACE in patients with stable CAD. When stratified by hs-cTnI level, SI independently predicted MACE-free survival only in those with elevated hs-cTnI (HR 1.51, 95% CI 1.01-2.24, P =?0.04).<h4>Conclusions</h4>SI independently predicted MACE in patients with stable CAD and high hs-cTnI, but not in those with low hs-cTnI. Hs-cTnI may be used to stratify stable CAD patients who have SI for intensive lipid-lowering therapy using non-statin agents.
Project description:<h4>Background</h4>In this study, we compared the outcomes of medical therapy (MT) with successful percutaneous coronary intervention (PCI) in chronic total occlusions (CTO) patients with and without type 2 diabetes mellitus.<h4>Methods</h4>A total of 2015 patients with CTOs were stratified. Diabetic patients (n?=?755, 37.5%) and non-diabetic patients (n?=?1260, 62.5%) were subjected to medical therapy or successful CTO-PCI. We performed a propensity score matching (PSM) to balance the baseline characteristics. A comparison of the major adverse cardiac events (MACE) was done to evaluate long-term outcomes.<h4>Results</h4>The median follow-up duration was 2.6 years. Through multivariate analysis, the incidence of MACE was significantly higher among diabetic patients compared to the non-diabetic patients (adjusted hazard ratio [HR] 1.32, 95% confidence interval [CI] 1.09-1.61, p?=?0.005). Among the diabetic group, the rate of MACE (adjusted HR 0.61, 95% CI 0.42-0.87, p?=?0.006) was significantly lower in the successful CTO-PCI group than in the MT group. Besides, in the non-diabetic group, the prevalence of MACE (adjusted HR 0.85, 95% CI 0.64-1.15, p?=?0.294) and cardiac death (adjusted HR 0.94, 95% CI 0.51-1.70, p?=?0.825) were comparable between the two groups. Similar results as with the early detection were obtained in propensity-matched diabetic and non-diabetic patients. Notably, there was a significant interaction between diabetic or non-diabetic with the therapeutic strategy on MACE (p for interaction?=?0.036).<h4>Conclusions</h4>For treatment of CTO, successful CTO-PCI highly reduces the risk of MACE in diabetic patients when compared with medical therapy. However, this does not apply to non-diabetic patients.
Project description:<h4>Background</h4>High-density lipoprotein (HDL) has cardioprotective properties. Each HDL particle has a few molecules of apolipoprotein A-I (apoA-I) and carries various amounts of cholesterol. The ratio of high-density lipoprotein cholesterol (HDL-C) to apoA-I may reflect mean HDL particle size.<h4>Hypothesis</h4>HDL-C/apoA-I ratio may provide more information than HDL-C and apoA-I in predicting myocardial injury following elective percutaneous coronary intervention (PCI).<h4>Methods</h4>We prospectively enrolled 2529 consecutive patients who underwent elective PCI and assessed the relationships of preprocedural HDL-C, apoA-I, and their ratio with peak cardiac troponin I (cTnI) within 24 hours after PCI.<h4>Results</h4>Neither HDL-C nor apoA-I levels showed significant association with postprocedural cTnI elevation, whereas HDL-C/apoA-I ratio was associated with postprocedural cTnI elevation above 3 up to 30 × upper limit of normal (ULN), with the lowest risk in the middle quintile (all P values for quadratic term were <0.05). Adjusted odds ratios (95% confidence interval) of postprocedural cTnI >3 × ULN for quintile 1 to 5 of HDL-C/apoA-I ratio were: 1 (reference), 0.81 (0.62-1.07), 0.57 (0.43-0.75), 0.65 (0.49-0.85), and 0.76 (0.58-1.01), respectively, and the adjusted odds ratios of postprocedural cTnI >30 × ULN for quintile 1 to 5 of HDL-C/apoA-I ratio were: 1 (reference), 0.81 (0.49-1.361), 0.42 (0.23-0.77), 0.66 (0.38-1.14), and 0.82 (0.49-1.38), respectively.<h4>Conclusions</h4>There was a U-shaped association between HDL-C/apoA-I ratio and myocardial injury following PCI.
Project description:<h4>Background</h4>The development of the technique has improved the success rate of percutaneous coronary intervention (PCI) for in-stent chronic total occlusion (IS-CTO). However, long-term outcomes remain unclear. The present study sought to investigate long-term outcomes of PCI for IS-CTO.<h4>Methods</h4>A total of 474 IS-CTO patients were enrolled at two cardiac centers from 2015 to 2018 retrospectively. These patients were allocated into either successful or failed IS-CTO PCI groups. The primary endpoint (major adverse cardiac events [MACE]) consisted of recurrent angina pectoris (RAP), target-vessel myocardial infarction (MI), heart failure, cardiac death, or ischemia-driven target-vessel revascularization (TVR) at follow-up. Multivariable Cox regression analysis was used to investigate the association between treatment appropriateness and clinical outcomes.<h4>Results</h4>A total of 367 patients were successfully treated with IS-CTO PCI while 107 patients had failed recanalization. After a median follow-up of 30 months (interquartile range: 17-42 months), no significant difference was observed between the two groups for the following parameters: cardiac death (successful PCI vs. failed PCI: 0.9% vs. 2.7%; adjusted hazard ratio [HR]: 1.442; 95% confidence interval [CI]: 0.21-9.887; P?=?0.709), RAP (successful PCI vs. failed PCI: 40.8% vs. 40.0%; adjusted HR: 1.025; 95% CI: 0.683-1.538; P?=?0.905), heart failure (successful PCI vs. failed PCI: 6.1% vs. 2.7%; adjusted HR: 0.281; 95% CI: 0.065-1.206; P?=?0.088), target-vessel related MI (successful PCI vs. failed PCI: 1.5% vs. 2.7%; adjusted HR: 1.150; 95% CI: 0.221-5.995; P?=?0.868), MACE (successful PCI vs. failed PCI: 44.2% vs. 45.3%; adjusted HR: 1.052; 95% CI: 0.717-1.543; P?=?0.797). More patients were free of angina in the successful IS-CTO PCI group compared with failed PCI in the first (80.4% vs. 60%, P?<?0.01) and second years (73.3% vs. 60.0%, P?=?0.02) following up. Successful IS-CTO PCI had a lower incidence of MACE in the first and second years (20.2% vs. 40.0%, P?<?0.01; 27.9% vs. 41.3%, P?=?0.023) compared with failed PCI. After a median follow-up of 30 months, the reocclusion rate was 28.5% and TVR was 26.1% in the successful IS-CTO PCI group. Receiving >18 months of dual antiplatelet therapy (DAPT) was an independent predictor of decreased risk of TVR (HR: 2.682; 95% CI: 1.295-5.578; P?=?0.008) or MACE (without TVR) (HR: 1.898; 95% CI: 1.036-3.479; P?=?0.038) in successful IS-CTO PCI.<h4>Conclusions</h4>After a median follow-up of 30 months, the successful IS-CTO PCI group had MACE similar to that of the failed PCI group. However, the successful IS-CTO PCI group had improved angina symptoms and were free from requiring coronary artery bypass grafting in the first or second years. To decrease MACE, DAPT was found to be essential and recommended for at least 18 months for IS-CTO PCI.
Project description:<h4>Objective</h4>This study aimed to compare outcomes of percutaneous coronary intervention (PCI) for chronic total occlusions (CTO) in the elderly (?75?years) versus nonelderly and assess the impact of successful CTO-PCI in the elderly.<h4>Methods</h4>PubMed, Embase, ScienceDirect, CENTRAL, and Google Scholar databases were searched up to October 1, 2020. Mortality rates and major adverse cardiac events (MACE) were compared between elderly and nonelderly patients and successful versus failed CTO-PCI in the elderly.<h4>Results</h4>Eight studies were included. Meta-analysis indicated no statistically significant difference in the risk of in-hospital mortality (RR: 1.97 95% CI: 0.78, 4.96 I<sup>2</sup> =?0% p = .15) but higher tendency of in-hospital MACE (RR: 2.30 95% CI: 0.99, 5.35 I<sup>2</sup> =?49% p = .05) in the elderly group. Risk of long-term mortality (RR: 3.79 95% CI: 2.84, 5.04 I<sup>2</sup> =?41% p?<?.00001) and long-term MACE (RR: 1.53 95% CI: 1.14, 2.04 I<sup>2</sup> =?80% p = .004) were significantly increased in the elderly versus nonelderly. Elderly patients had a significantly reduced odds of successful PCI as compared to nonelderly patients (OR: 0.63 95% CI: 0.54, 0.73 I<sup>2</sup> =?1% p?<?.00001). Successful CTO-PCI was associated with reduction in long-term mortality (HR: 0.51 95% CI: 0.34, 0.77 I<sup>2</sup> =?27% p = .001) and MACE (HR: 0.60 95% CI: 0.37, 0.97 I<sup>2</sup> =?53% p = .04) as compared to failed PCI in elderly.<h4>Conclusions</h4>Elderly patients may have a tendency of higher in-hospital MACE with significantly increased long-term mortality and MACE after CTO-PCI. The success of PCI is significantly lower in the elderly. In elderly patients with successful PCI, the risk of long-term mortality and MACE is significantly reduced.
Project description:<h4>Importance</h4>Data are lacking on the outcomes of patients with severely reduced left ventricular ejection fraction (LVEF) who undergo revascularization by percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG).<h4>Objective</h4>To compare the long-term outcomes in patients undergoing revascularization by PCI or CABG.<h4>Design, setting, and participants</h4>This retrospective cohort study performed in Ontario, Canada, from October 1, 2008, and December 31, 2016, included data from Ontario residents between 40 and 84 years of age with LVEFs less than 35% and left anterior descending (LAD), left main, or multivessel coronary artery disease (with or without LAD involvement) who underwent PCI or CABG. Exclusion criteria were concomitant procedures, previous CABG, metastatic cancer, dialysis, CABG and PCI on the same day, and emergency revascularization within 24 hours of a myocardial infarction (MI). Data analysis was performed from June 2, 2018, to December 28, 2018.<h4>Exposures</h4>Revascularization by PCI or CABG.<h4>Main outcomes and measures</h4>The primary outcome was all-cause mortality. Secondary outcomes were death from cardiovascular disease, major adverse cardiovascular events (MACE; defined as stroke, subsequent revascularization, and hospitalization for MI or heart failure), and each of the individual MACE.<h4>Results</h4>A total of 12 113 patients (mean [SD] age, 64.8 (11.0) years for the PCI group and 65.6 [9.7] years for the CABG group; 5084 (72.5%) male for the PCI group and 4229 (82.9%) male for the PCI group) were propensity score matched on 30 baseline characteristics: 2397 patients undergoing PCI and 2397 patients undergoing CABG. The median follow-up was 5.2 years (interquartile range, 5.0-5.3). Patients who received PCI had significantly higher rates of mortality (hazard ratio [HR], 1.6; 95% CI, 1.3-1.7), death from cardiovascular disease (HR 1.4, 95% CI, 1.1-1.6), MACE (HR, 2.0; 95% CI, 1.9-2.2), subsequent revascularization (HR, 3.7; 95% CI, 3.2-4.3), and hospitalization for MI (HR, 3.2; 95% CI, 2.6-3.8) and heart failure (HR, 1.5; 95% CI, 1.3-1.6) compared with matched patients who underwent CABG.<h4>Conclusions and relevance</h4>In this study, higher rates of mortality and MACE were seen in patients who received PCI compared with those who underwent CABG. The findings may provide insight to physicians who are involved in decision-making for these patients.
Project description:<h4>Importance</h4>Loading doses of atorvastatin did not show reduction on clinical outcomes in the overall population of patients with acute coronary syndrome (ACS) enrolled in the Statins Evaluation in Coronary Procedures and Revascularization (SECURE-PCI) trial, but a potential benefit was identified in patients who subsequently underwent percutaneous coronary intervention (PCI).<h4>Objectives</h4>To determine whether periprocedural loading doses of atorvastatin are associated with decreased 30-day major adverse cardiovascular events (MACE) in patients with ACS undergoing PCI according to type of ACS and timing of atorvastatin administration before PCI.<h4>Design, setting, and participants</h4>Secondary analysis of a multicenter, double-blind, placebo-controlled, randomized clinical trial conducted at 53 sites that enrolled 4191 patients with ACS intended to be treated with PCI between April 18, 2012, and October 06, 2017.<h4>Interventions</h4>Patients were randomized to 2 loading doses of 80 mg of atorvastatin or matching placebo before and 24 hours after a planned PCI. By protocol, all patients (regardless of treatment group) received 40 mg of atorvastatin for 30 days starting 24 hours after the second dose of study medication.<h4>Main outcomes and measures</h4>The primary outcome was MACE through 30 days, composed by all-cause mortality, myocardial infarction, stroke, and unplanned coronary revascularization. Cox regression models adjusting for key baseline characteristics were used to assess the association between atorvastatin and MACE in patients undergoing PCI.<h4>Results</h4>From the overall trial population, 2710 (64.7%) underwent PCI (650 women [24.0%]; mean [SD] age, 62 [11.3] years). Loading atorvastatin was associated with reduced MACE at 30 days by 28% in the PCI group (adjusted hazard ratio [HR], 0.72; 95% CI 0.54-0.97; P = .03). Loading dose of atorvastatin was administered less than 12 hours before PCI in 2548 patients (95.3%) (45.1% < 2 hours and 54.3% between 2 and 12 hours). There was no significant interaction between treatment effect and timing of study drug administration. The treatment effect of loading atorvastatin was more pronounced in patients with ST-segment elevation myocardial infarction than in patients with non-ST-segment elevation ACS (adjusted HR, 0.59; 95% CI, 0.38-0.92; P = .02; HR, 0.85; 95% CI, 0.58-1.27; P = .43, respectively).<h4>Conclusions and relevance</h4>In patients with ACS undergoing PCI, periprocedural loading doses of atorvastatin appeared to reduce the rate of MACE at 30 days, most clearly in patients with ST-segment elevation myocardial infarction. This beneficial effect seemed to be preserved and consistent, irrespective of the timing of atorvastatin administration, including within 2 hours before PCI.<h4>Trial registration</h4>clinicaltrials.gov Identifier: NCT01448642.
Project description:Phosphate has been linked to higher cardiovascular (CV) risk. However, whether phosphate is associated with poor outcomes for patients with coronary artery disease (CAD) after percutaneous coronary interventions (PCIs) remained undetermined. 2,894 CAD patients (2,220 male, aged 71.6 ± 12.2), who received PCI at TVGH from 2006 to 2015, with phosphate measurement, were enrolled. The primary outcome was the composite of major adverse CV events [MACE, comprising of CV death, nonfatal MI, and nonfatal stroke] and heart failure hospitalization (HHF). The key secondary outcome was MACE. There was a J-curve association between phosphate and CV events after adjusted for comorbidities and renal function. Phosphate around 3.2 ± 0.1 mg/dL was associated with the lowest CV risk. In Cox analysis, each 1 mg/dL increases in phosphate was associated with a higher risk of MACE + HHF (HR: 1.12, 95% CI: 1.05-1.21): CV death (HR: 1.37, 95% CI: 1.22-1.55) and HHF (HR: 1.12, 95% CI: 1.02-1.23). Subgroup analyses showed more prominent association between phosphate and MACE + HHF in male, age > 65, bare-metal stents (BMSs), LVEF < 50%, eGFR < 60, LDL > 70 mg/dL, and emergent PCI. Phosphate has a significant association with the risk of CV events in CAD patients undergoing PCI that was independent of comorbidities and renal function.
Project description:<h4>Background</h4>Risk stratification of patients with non-ST-elevation acute coronary syndrome (NSTE-ACS) is an important clinical method, but long-term studies on patients subjected to all-treatment strategies are lacking. Therefore, the aim was to compare several established risk scores in the all-treatment NSTE-ACS cohort during long-term follow-up.<h4>Methods</h4>Consecutive patients (n?=?276) with NSTE-ACS undergoing coronary angiography were recruited between September 2012 and May 2015. Six risk scores for all patients were calculated, namely GRACE 2.0, ACEF, SYNTAX, Clinical SYNTAX, SYNTAX II PCI and SYNTAX II CABG. The primary end-point was Major Adverse Cardiovascular Events (MACE) which was a composite of cardiac death, nonfatal myocardial infarction, ischemic stroke or urgent coronary revascularization.<h4>Results</h4>During a median follow-up of 33 months, 64 MACE outcomes were recorded (23.2%). There was no difference between risk score categories, except in the highest risk group of ACEF and SYNTAX II PCI scores which exhibited significantly more MACE (51.6%, N?=?33 and 45.3%, N?=?29, P?=?0.024, respectively). In the multivariate Cox regression analysis of individual variables, only age and atrial fibrillation were significant predictors for MACE (HR 1.03, 95% CI 1.00-1.05, P?=?0.023 and HR 2.02, 95% CI 1.04-3.89, P?=?0.037, respectively). Furthermore, multivariate analysis of the risk scores showed significant prediction of MACE only with ACEF score (HR 2.16, 95% CI 1.36-3.44, P?=?0.001). The overall performance of GRACE, SYNTAX, Clinical SYNTAX and SYNTAX II CABG was poor with AUC values of 0.596, 0.507, 0.530 and 0.582, respectively, while ACEF and SYNTAX II PCI showed the best absolute AUC values for MACE (0.630 and 0.626, respectively).<h4>Conclusions</h4>ACEF risk score showed better discrimination than other risk scores in NSTE-ACS patients undergoing all-treatment strategies over long-term follow-up and it could represent a fast and user-friendly tool to stratify NSTE-ACS patients.