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It is important that the medical profession play a significant role in critically evaluating the use of diagnostic procedures and therapies as they are introduced in the detection, management,

/pdf/acc-aha-2006-guidelines-for-the-management-of-patients-with-27qfh9fc7i.pdf

ACC/AHA 2006 Guidelines for the Management of Patients With Valvular Heart Disease

ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation : The Task Force for the management of acute coronary syndromes (ACS) in patients presenting without persistent ST-segment elevation of the European Society of Cardiology (ESC).

/pdf/2015-esc-guidelines-for-the-management-of-acute-coronary-6did6h5nxk.pdf

2015 ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation: Task Force for the Management of Acute Coronary Syndromes in Patients Presenting without Persistent ST-Segment Elevation of the European Society of Cardiology (ESC)

2018 ESC/EACTS Guidelines on myocardial revascularization.

We conducted a randomized trial involving 2287 patients who had objective evidence of myocardial ischemia and significant coronary artery disease at 50 U.S. and Canadian centers. Between 1999 and 2004, we assigned 1149 patients to undergo PCI with optimal medical therapy (PCI group) and 1138 to receive optimal medical therapy alone (medical-therapy group). The primary outcome was death from any cause and nonfatal myocardial infarction during a follow-up period of 2.5 to 7.0 years (median, 4.6). Results There were 211 primary events in the PCI group and 202 events in the medicaltherapy group. The 4.6-year cumulative primary-event rates were 19.0% in the PCI group and 18.5% in the medical-therapy group (hazard ratio for the PCI group, 1.05; 95% confidence interval [CI], 0.87 to 1.27; P = 0.62). There were no significant differences between the PCI group and the medical-therapy group in the composite of death, myocardial infarction, and stroke (20.0% vs. 19.5%; hazard ratio, 1.05; 95% CI, 0.87 to 1.27; P = 0.62); hospitalization for acute coronary syndrome (12.4% vs. 11.8%; hazard ratio, 1.07; 95% CI, 0.84 to 1.37; P = 0.56); or myocardial infarction (13.2% vs. 12.3%; hazard ratio, 1.13; 95% CI, 0.89 to 1.43; P = 0.33). Conclusions As an initial management strategy in patients with stable coronary artery disease, PCI did not reduce the risk of death, myocardial infarction, or other major cardiovascular events when added to optimal medical therapy. (ClinicalTrials.gov number, NCT00007657.)

https://www.medpagetoday.com/upload/2007/4/25/COURAGE1.pdf

Optimal Medical Therapy with or without PCI for Stable Coronary Disease

Chronic kidney disease1 (CKD) is a worldwide public health problem. In the United States, there is a rising incidence and prevalence of kidney failure, with poor outcomes and high cost. The number of individuals with kidney failure treated by dialysis and transplantation exceeded 320 000 in 1998 and is expected to surpass 650 000 by 2010.1,2 There is an even higher prevalence of earlier stages of CKD (Table 1).1,3 Kidney failure requiring treatment with dialysis or transplantation is the most visible outcome of CKD. However, cardiovascular disease (CVD) is also frequently associated with CKD, which is important because individuals with CKD are more likely to die of CVD than to develop kidney failure,4 CVD in CKD is treatable and potentially preventable, and CKD appears to be a risk factor for CVD. In 1998, the National Kidney Foundation (NKF) Task Force on Cardiovascular Disease in Chronic Renal Disease issued a report emphasizing the high risk of CVD in CKD.5 This report showed that there was a high prevalence of CVD in CKD and that mortality due to CVD was 10 to 30 times higher in dialysis patients than in the general population (Figure 1 and Table 2).6–18 The task force recommended that patients with CKD be considered in the “highest risk group” for subsequent CVD events and that treatment recommendations based on CVD risk stratification should take into account the highest-risk status of patients with CKD. 

View this table:

TABLE 1. Stages of CKD 





Figure 1. Cardiovascular mortality defined by death due to arrhythmias, cardiomyopathy, cardiac arrest, myocardial infarction, atherosclerotic heart disease, and pulmonary edema in general population (GP; National Center for Health Statistics [NCHS] multiple cause of mortality data files International Classification of Diseases, 9th Revision [ICD 9] codes 402, 404, 410 to 414, and …

Kidney disease as a risk factor for development of cardiovascular disease: a statement from the American Heart Association Councils on Kidney in Cardiovascular Disease, High Blood Pressure Research, Clinical Cardiology, and Epidemiology and Prevention.

ObjectivePrevious studies have suggested that intensive statin therapy, compared with moderate statin therapy, provided greater reduction of LDL and better protection against major cardiovascular events. However, the exact dose-dependent mechanism of plaque stabilization remains unclear. The aim of this study is to investigate the three-dimensional (3D) response of fibrous caps overlying lipid plaques to statin therapy. MethodsWe applied a novel computer algorithm to investigate the fibrous cap 3D morphological change over time in patients with coronary artery disease. Patients were treated with either atorvastatin 20 mg/day (moderate intensity) or atorvastatin 60 mg/day (high intensity). Optical coherence tomography was performed at baseline, 6, and 12 months. A total of 31 lipid plaques from 21 patients were analyzed. ResultsConventional metrics such as the minimum fibrous cap thickness change between the two treatment groups were not significantly different between the baseline and the 12-month follow-up. In contrast, the 3D metric thin cap (<80 &mgr;m) surface area change between the baseline and the 12-month follow-up showed dose-dependent, significant differences between the statin treatment groups (P<0.001). 3D reconstructions of fibrous caps further indicated that fibrous caps showed diverse (scattered vs. confluent) patterns and could evolve in a complex manner. ConclusionHigh-intensity statin therapy more effectively stabilized fibrous caps at follow-up. The new 3D algorithm provided more comprehensive and detailed information on the changes in plaque phenotype in response to statin therapy.

Three-dimensional morphological response of lipid-rich coronary plaques to statin therapy

Pursuit for the detection of vulnerable plaque

Objective

To better characterize intrastent pathology using optical coherence tomography (OCT) in patients presenting with late and very late stent thrombosis (LST/VLST).



Background

The contribution of specific intrastent pathologies to the development of LST/VLST is not well understood.



Methods

In this single-center, retrospective, observational study of 796 consecutive patients treated for ST-segment elevation myocardial infarction (STEMI) with primary PCI we identified 57 patients (7.2%) in whom STEMI resulted from LST/VLST. Of the patients with LST/VLST, 21 patients (37%) had OCT performed at the discretion of the operator during PCI for LST/VLST. Independent reviewers performed qualitative offline analysis of OCT images to determine the cause of stent thrombosis defined as the specific intrastent pathology associated with thrombus deposition.



Results

The principal intrastent pathology causing LST/VLST was determined to be stent malapposition in 11 patients (55%), of which 5 (25% of all LST/VLST patents) had findings suggestive of positive vessel remodeling. Neoatherosclerosis was determined to be the cause of LST/VLST in 7 patients (35%). LST/VLST resulted from uncovered stent struts in 2 patients (10%). Among all LST/VLST patients, in-hospital mortality (12.3%) and post-hospital target vessel failure (TVF) or cardiac death (21.7%, median follow-up 1.6 years) remained high. There was a trend towards decreased TVF or cardiac death (7.7% vs. 27.3% P = 0.24) in patients who underwent OCT-guided therapy.



Conclusions

LST/VLST remains a significant cause of STEMI and is associated with considerable morbidity and mortality. OCT use at the time of PCI consistently identifies significant intrastent pathology with potentially meaningful clinical impact. (J Interven Cardiol 2015;28:439–448)

Identification of Intrastent Pathology Associated With Late Stent Thrombosis Using Optical Coherence Tomography.

Objective — The HeartVue TM 6S System is a recently developed novel technology that may provide non-invasive assessment of myocardial ischaemia by analysing low amplitude oscillations of the conventional ECG signals (ECG dispersion mapping). The available data to validate this new technology is limited.Therefore we performed a prospective study to assess the HeartVueTM 6S System for the detection of myocardial ischaemia during coronary occlusion in patients undergoing percutaneous coronary intervention (PCI). Methods — A total of 101∞∞patients undergoing cardiac catheterization were prospectively enrolled. HeartVueTM 6S System ECG dispersion mapping was obtained at baseline, and during the first balloon inflation and at the end of the procedure if PCI was performed. Parameters provided by the HeartVueTM 6S System were analysed. Results — Fifty patients who underwent PCI comprised the final study population. The mean age was 63.7∞∞±∞∞10∞∞years and 58% were men. In 58% of cases the indication was acute coronary syndrome. In 98% of patients, PCI was successful. There were significant differences in the G7+G9 values between the first inflation and the end of the procedure, which reflect changes in ventricular depolarization (P =∞∞0.02 by Wilcoxon signed rank test). Conclusions — The HeartVueTM 6S System may have potential for a non-invasive assessment of ischaemia in patients with suspected coronary artery disease. Larger studies are warranted to confirm these preliminary findings.

/pdf/non-invasive-assessment-of-myocardial-ischaemia-by-using-low-4tsjwod3gd.pdf

Non-invasive assessment of myocardial ischaemia by using low amplitude oscillations of the conventional ECG signals (ECG dispersion mapping) during percutaneous coronary intervention.

Optical coherence tomography (OCT) is a catheter-based modality that enables in vivo imaging of coronary arteries with 10-fold improved resolution compared with intravascular ultrasonography. The high resolution of OCT imaging allows it to serve as an “optical biopsy,” facilitating detailed plaque characterization and evaluation of features associated with plaque vulnerability. Limitations of OCT include its limited depth of penetration and the need to create a bloodfree field during imaging. Improvements in image acquisition speed have enabled the translation of OCT from the research setting to clinical practice, and studies are now underway to evaluate OCT-guided decision making.

https://www.interventional.theclinics.com/article/S2211-7458(15)00007-3/pdf

Ik-Kyung Jang

Papers

Three-dimensional morphological response of lipid-rich coronary plaques to statin therapy

Pursuit for the detection of vulnerable plaque

Identification of Intrastent Pathology Associated With Late Stent Thrombosis Using Optical Coherence Tomography.

Non-invasive assessment of myocardial ischaemia by using low amplitude oscillations of the conventional ECG signals (ECG dispersion mapping) during percutaneous coronary intervention.

Fundamentals of Optical Coherence Tomography: Image Acquisition and Interpretation