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Polymer-Free Drug-Coated Coronary Stents in Patients with Stable Coronary Artery Disease at High Bleeding RiskPanchal, Hemang B., Daggubati, Ramesh, Zhao, David, Rao, Sunil V., Paul, Timir 01 February 2017 (has links)
Purpose of Review: Patients with stable coronary artery disease (CAD) and a high risk of bleeding are not ideal candidates for a polymer-based drug-eluting stent (DES) because it requires 6–12 months of dual antiplatelet therapy (DAPT) following percutaneous coronary intervention (PCI). The purpose of this review is to assess the angiographic and clinical outcomes of polymer-free drug-coated stents (PF-DCS) in stable CAD patients with a high bleeding risk. Recent Findings: Several randomized controlled trials (RCTs) have compared angiographic and clinical outcomes of PF-DCS with bare-metal stents (BMS), permanent polymer (PP)-DES, or biodegradable polymer (BP)-DES. However, none of these studies particularly recruited patients with stable CAD and a high risk of bleeding. Furthermore, there are limited data available on duration of DAPT following PF-DCS placement. Summary: PF-DCS has a better efficacy and similar safety as compared with BMS. PF-DCS with dual drug is noninferior to currently available PP-DES. Further RCTs are needed to assess the safety and efficacy of PF-DCS to BP-DES and PP-DES comparing shorter to standard durations of DAPT.
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Déterminants du pronostic de la maladie coronarienne stable / Determinants of the prognosis of stable coronary artery diseaseSorbets, Emmanuel 18 September 2017 (has links)
Les patients coronariens stables ou stabilisés sont à haut risque d’évènements cardiovasculaires. Ils représentent une population hétérogène avec une présentation clinique, un terrain et un pronostic pouvant être extrêmement variables d’un patient à l’autre. Pourtant, d’après les recommandations internationales, tous doivent bénéficier d’une prise en charge relativement comparable basée sur des essais cliniques réalisés dans des sous-populations restreintes de patients stables et instables, pour la plupart anciens, et ne correspondant plus à la prise en charge actuelle des patients. Préciser les déterminants du pronostic de cette population, et notamment les stratégies thérapeutiques, est un enjeu majeur.Les antagonistes du système rénine-angiotensine (IEC/ARA2) font partie de l’arsenal médicamenteux de tout patient coronarien. Pourtant leur intérêt, en association aux antiagrégants plaquettaires et statines, est incertain chez les patients sans dysfonction ventriculaire gauche qui constituent un sous-groupe important parmi les patients stables.Le registre international REACH a évalué l’impact des IEC/ARA2 dans cette population avec 4 ans de suivi. La méthodologie statistique utilisée a été une analyse observationnelle avec ajustement ou avec appariement selon le score de propension. Il n’a pas été mis en évidence de bénéfice des IEC/ARA2 sur le critère de jugement principal composite associant décès cardiovasculaire – IDM – AVC, de même que sur le critère de jugement secondaire associant décès cardiovasculaire – IDM – AVC – Hospitalisation pour évènement athéro-thrombotique ou sur les critères tertiaires comprenant individuellement chacun des critères de jugement secondaire ainsi que sur la mortalité toute cause. Enfin il n’est pas ressorti non plus de bénéfice franc dans les sous-groupes d’analyse. Les résultats ont été concordants lorsque les analyses ont été réalisées pour les IEC seuls ou pour les ARA2 seuls, et ont été confortés par diverses analyses de sensibilité.Ces données méritent confirmation dans une cohorte indépendante. C’est l’un des objectifs du registre CLARIFY, registre de 32703 patients coronariens stables ou stabilisés, dont le suivi à 5 ans est terminé. Dans ce registre contemporain international, le taux global à 5 ans de mortalité toute cause a été de 7,9%, de mortalité non cardiovasculaire de 5% et de mortalité cardiovasculaire de 2,9%. Un évènement cardiovasculaire comprenant infarctus du myocarde (fatal ou non), angor instable, revascularisation coronaire par angioplastie ou pontage est survenu chez 15,9% des patients.Tout comme les IEC/ARA2, l’impact des bétabloquants dans la prise en charge du coronarien stable ou stabilisé, sans dysfonction ventriculaire est également controversé. Cette classe médicamenteuse est en cours d’évaluation dans CLARIFY. L’analyse tient compte du type de bétabloquant, de la dose prescrite, des éventuelles intolérances amenant à modifier leur utilisation, de la présence et de l’ancienneté d’un infarctus du myocarde et la fraction d’éjection ventriculaire gauche.CLARIFY a également pour objectif d’approfondir les déterminants du pronostic de la maladie coronarienne stable, avec une analyse spécifiquement focalisée sur la présence de symptômes angineux, d’ischémie myocardique et sur leur combinaison, en fonction de l’utilisation des méthodes de revascularisation myocardiques, pour mieux comprendre les mécanismes responsables des évènements cardiovasculaires et évoluer vers une prise en charge plus personnalisée. / Stable or stabilized coronary artery disease patients are at high risk for cardiovascular events. They represent a heterogeneous population. The clinical presentation, the context and the prognosis can be extremely variable from one patient to another. However, according to the international guidelines, those patients should be given a relatively comparable treatment based on clinical trials realized in restricted subpopulations of stable and unstable patients. Most of these trials are old, and no longer correspond to the current management. Specifying the determinants of the prognosis of this population, and in particular the therapeutic strategies, is a major challenge.The antagonist receptors of renin-angiotensin system (ACEI/ARB) are a part of the treatment of any coronary artery disease patient. Yet their interest in the prognosis of this population without left ventricular dysfunction in association with antiplatelet agents and statins is uncertain.The contemporary REACH registry has assessed the impact of ACEI/ARB in this population with a 4-year of follow-up. The statistical methodology used was based on the propensity score. After adjustment or matching with the propensity score, there was no benefit of ACEI/ARB on the primary endpoint of cardiovascular death - MI - stroke. No benefit was found on the secondary endpoint of cardiovascular death - MI - stroke - hospitalization for atherothrombotic events. No benefit was found on the tertiary criteria including individually each of the secondary endpoints and on any cause mortality. Finally,there was no clear benefit in the analyzes subgroups. These results were consistent when the analyzes were performed for ACEI alone or for ARB alone. They were also supported by sensitivity analyzes.These data should be confirmed or reversed in an independent cohort. This will be one of the many objectives of the CLARIFY registry, that enrolled 32,703 stable or stabilized coronary artery disease patients. The 5-year follow-up is complete. In this international contemporary registry, the overall 5-year rate of total mortality was 7.9%, non-cardiovascular mortality was 5% and cardiovascular mortality was 2.9%. A cardiovascular event including myocardial infarction (fatal or not), unstable angina, coronary revascularization by angioplasty or bypass surgery occured in 15.9% of patients.Like ACEI/ARB, the impact of betablockers on the management of stable or stabilized coronary artery disease without left ventricular dysfunction is also controversial. This drug class is being evaluated in CLARIFY. The analyzis takes into account the type of beta-blocker, the prescribed dose, any intolerance leading to changes in their use, the history of a myocardial infarction, and the left ventricular ejection fraction.CLARIFY will help to more define the determinants of the prognosis of stable coronary artery disease, with a more particular focus on symptomatic or not, ischemic or not, and revascularized or not, in order to better understand the mechanisms responsible for cardiovascular events, and evolve towards a more personalized and cost-effective care.
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Biomarkers for Non-Invasive Stratification of Coronary Artery Disease and Prognostic Impact on Long-Term Survival in Patients with Stable Coronary Heart DiseaseNetto, Jeffrey, Teren, Andrej, Burkhardt, Ralph, Willenberg, Anja, Beutner, Frank, Henger, Sylvia, Schuler, Gerhard, Thiele, Holger, Isermann, Berend, Thiery, Joachim, Scholz, Markus, Kaiser, Thorsten 15 January 2024 (has links)
Knowledge about cardiac and inflammatory biomarkers in patients with stable coronary
artery disease (CAD) is limited. To address this, we analyzed 3072 patients (36% female) with a
median follow-up of 10 years in the Leipzig LIFE Heart Study with suspected CAD with coronary
angiography. Selected biomarkers included troponin T (hsTNT), N-terminal pro B-type natriuretic
peptide (NT-proBNP), copeptin, C-reactive protein (hsCRP), and interleukin-6 (IL-6). Patients were
stratified by CAD severity: CAD0 (no sclerosis), CAD1 (non-obstructive, i.e., stenosis < 50%), and
CAD2 (one stenosis 50%). Group comparison (GC) included GC1: CAD0 + 1 vs. CAD2; GC2:
CAD0 vs. CAD1 + 2. CAD0, CAD1, and CAD2 were apparent in 1271, 631, and 1170 patients,
respectively. Adjusted for classical risk factors, hs-cTnT, NT-proBNP, and IL-6 differed significantly
in both GC and hsCRP only in GC2. After multivariate analysis, hs-cTnT, NT-proBNP, and IL-6
remained significant in GC1. In GC2, hs-cTnT (p < 0.001) and copeptin (p = 0.014) reached significance.
Ten-year survival in groups CAD0, CAD1, and CAD2 was 88.3%, 77.3%, and 72.4%. Incorporation of
hs-cTnT, NT-proBNP, copeptin, and IL-6 improved risk prediction (p < 0.001). The studied cardiac
and inflammatory biomarkers enable fast and precise non-invasive identification of mortality risk in
CAD patients, allowing the tailoring of primary and secondary CAD prevention.
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