Putting Timing to the Test

What is the current time interval between stroke and carotid endarterectomy (CEA) or carotid artery stenting (CAS) and the proportion of procedures occurring within 14 days? This was the question that researchers using validated International Classification of Diseases, Ninth Revision, Clinical Modification codes and administrative claims data from nonfederal hospitals in California, Florida and New York asked in a recent study published in Stroke.

Researchers identified 16,298 patients with ischemic stroke who underwent CEA or CAS within 90 days of an ischemic stroke from 2005 to 2013. Outcomes were the number of days between stroke and CEA/CAS and the proportion of patients undergoing CEA/CAS within the recommended 14-day period. The authors assessed temporal trends using nonparametric correlation, the χ2 test for trend, and logistic regression.

Overall results found that since 2005, revascularization for symptomatic carotid disease has been occurring progressively sooner after ischemic stroke. Specifically, the time from stroke to CEA/CAS decreased from 25 days (interquartile range, 5-48 days) in 2005 to six days (interquartile range, 3-17 days) in 2013 (p < 0.001). The proportion of patients who underwent CEA/CAS within 14 days of stroke increased from 40 percent in 2005 to 73 percent in 2013. Researchers noted that these temporal trends remained significant after adjustment for patient demographics and comorbidities.

“This study reports that since 2006 when the American Heart Association released its recommendation to perform carotid revascularization procedures within 14 days of a stroke, progressively more of these procedures are being performed in a relatively timely manner among patients who present with ischemic stroke in California, Florida and New York,” writes Debabrata Mukherjee, MD, FACC, in an ACC.org Journal Scan. “Although this trend is encouraging, efforts to further promote earlier revascularization in the United States may still be beneficial because there remains a high risk of recurrent stroke even within the recommended 14-day window.”

Reznik M, Kamel H, Gialdini G, Pandva A, Navi BB, Gupta A. Stroke 2017;48:225-8.

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PCI and CABG Both Safe for Unprotected Left Main Coronary Artery Disease?

PCI with drug-eluting stents (DES) and CABG are equally safe for revascularization in patients at low surgical risk with significant unprotected left main coronary artery stenosis, according to recent findings from Circulation: Cardiovascular Interventions.

Researchers examined randomized trials comparing PCI and CABG for unprotected left main coronary artery stenosis and found five studies that met criteria for inclusion, with three trials comparing PCI using early-generation DES with CABG and two trials using newer-generation DES. Overall, 4,594 patients were included in the analysis with 2,297 (50 percent) patients undergoing PCI using a DES. The prevalence of unprotected left main coronary artery stenosis ranged from 10 percent to 29 percent with between 55 percent and 80 percent of patients having a bifurcation unprotected left main coronary artery lesion.

Overall, there was no significant difference in safety outcomes between PCI and CABG for the treatment of unprotected left main coronary artery stenosis. However, researchers highlight that PCI was less effective when compared with CABG due to significantly higher rates of repeat revascularization. The incidence of all-cause death, myocardial infarction and stroke did not differ between PCI and CABG.

Moving forward, the authors noted these findings are important for informing treatment decisions made by multidisciplinary teams worldwide.

“These data imply that PCI using DES for unprotected left main coronary artery disease is not harmful and should be considered an acceptable revascularization option,” the authors write. “However, this does not mean that undertaking PCI for unprotected left main coronary artery intervention is not without risk, and suboptimal PCI results may have profound implications for the patient… Ultimately, the decision on which revascularization strategy should be used rests with the patient, who should be fully informed of the risks and potential benefits of each treatment option by a multidisciplinary heart team that understands the local expertise available.”

Nerlekar N, Ha FJ, Verma KP, et al. Circ Cardiovasc Interv 2016;9:e004729.

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STEMI in Renal Transplant Recipients

In-hospital mortality rates in renal transplant recipients with a STEMI are more favorable compared with those of patients with stage 5D chronic kidney disease (CKD), according to a study published in JAMA: Cardiology.

Researchers used the National Inpatient Sample database to identify patients 18 years or older who were hospitalized with the principal diagnosis of STEMI. All hospitalizations for STEMI in the U.S. from Jan. 1, 2003 to Dec. 31, 2013, were included. Codes from International Classification of Diseases, Ninth Revision, Clinical Modification, were used to identify patients in non-CKD, stage 5D CKD, or prior renal transplant groups. All told, 319,002 patients were identified in the non-CKD group (34.7 percent women; 65.3 percent men; mean [SD] age, 64.2 [14.4] years); 30,072 patients were identified in the stage 5D CKD group (45.0 percent women; 55.0 percent men; mean [SD] age, 66.9 [12.5] years); and 2,980 patients were identified in the renal transplant group (27.3 percent women; 72.7 percent men; mean [SD] age, 57.5 [11.1] years). Of these, 68.9 percent of the patients in the non-CKD group, 39.5 percent in the stage 5D CKD group, and 65.2 percent in the renal transplant group received in-hospital reperfusion for STEMI. The main outcome measure was in-hospital mortality.

Results showed the renal transplant group was more likely to receive reperfusion compared with the stage 5D CKD group (adjusted odds ratio [AOR], 1.83; 95 percent confidence interval [CI], 1.67-2.01; p < 0.001), but less likely compared with the non-CKD group (AOR, 0.75; 95 percent CI, 0.68-0.83; p < 0.001). Researchers also noted that risk-adjusted in-hospital mortality among the renal transplant group with STEMI was markedly lower compared with the stage 5D CKD group, but similar compared with the non-CKD group. Among renal transplant recipients with STEMI, the use of reperfusion increased from 53.7 percent in the 2003-2004 interval to 81.4 percent in the 2011-2013 interval, whereas risk-adjusted in-hospital mortality remained unchanged during the study period (8.9 percent in the 2003-2004 interval to 6.1 percent in the 2011-2013 interval).

“Compared with the stage 5D CKD group, the renal transplant group was much more likely to receive reperfusion and had markedly lower risk-adjusted in-hospital mortality and shorter mean length of stay,” writes Debabrata Mukherjee, MD, FACC, in an ACC.org Journal Scan. “Additional prospective studies are indicated to confirm these findings and explore the mechanisms that may contribute to improved STEMI outcomes in renal transplant recipients versus those on dialysis. In addition, practicing clinicians should expedite STEMI diagnosis in patients with CKD and deliver appropriate timely reperfusion, given the low rates of reperfusion currently seen in this population.”

Gupta T, Kolte D, Khera S, et al. JAMA Cardiol 2017;Jan 11:[Epub ahead of print].

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Late Restenosis Seen with Both First- and Second-Generation DES

Late restenosis occurs after both first- and second-generation drug-eluting stent (DES) implantations in patients with DES restenosis, according to a recent study in Circulation: Cardiovascular Interventions.

Seiji Habara, MD, and colleagues collected data for 608 patients who received revascularization for DES restenosis between 2004 and 2012 and analyzed 688 lesions (359 lesions treated with a first-generation DES and 329 lesions treated with a second-generation DES). Two serial angiographic follow-ups were routinely planned for the patients at 8 and 20 months after the procedure.

Early follow-up angiography was performed for 620 lesions (90.1 percent), and recurrent restenosis occurred in 84 lesions (25.8 percent) in the first-generation group and in 72 lesions (24.5 percent) in the second-generation group. Target lesion revascularization was performed for 69 lesions (21.2 percent) in the first-generation group and for 48 lesions (16.3 percent) in the second-generation group. Late follow-up angiography was performed for 438 (87.1 percent) of the remaining 503 lesions (excluding target lesion revascularization lesions), with late restenosis found in 35 lesions (15.8 percent) in the first-generation group and in 28 lesions (14.7 percent) in the second-generation group. Late target lesion revascularization was performed for 26 lesions (11.3 percent) in the first-generation group and for 17 lesions (8.2 percent) in the second-generation group.

According to the study authors, nonfocal-type restenosis, percentage diameter stenosis after the procedure, previous stent size ≤ 2.5 mm, and right coronary artery ostial lesion were independent predictors of early restenosis. Nonfocal-type restenosis, percentage diameter stenosis at early follow-up, and stent fracture were independent predictors of late restenosis.

“Our results suggest that late restenosis occurs after both first-generation DES implantation and second-generation DES implantation for DES restenosis and that risk factors of recurrent restenosis after DES implantation for DES restenosis vary depending on the period of time after the procedure,” they write.

Habara S, Kadota K, Kuwayama A, et al. Circ Cardiovasc Interv 2016;9:e004449.

Keywords: ACC Publications, Cardiology Interventions, Angiography, Carotid Arteries, Carotid Artery, Common, Coronary Stenosis, Coronary Vessels, Drug-Eluting Stents, Endarterectomy, Carotid, Hospital Mortality, Hospitalization, Inpatients, International Classification of Diseases, Kidney Transplantation, Logistic Models, Outcome Assessment, Health Care, Stents, Stroke

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