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How Does SMuRF Status Impact Long-term Outcomes In Coronary Artery Disease?
Patients with stable coronary artery disease (CAD) but without standard modifiable cardiovascular risk factors (SMuRFs) have a substantial but significantly lower risk of long-term cardiovascular events than people with risk factors, an observational study has found.
Previous research found patients without SMuRFs presenting with first myocardial infarction (MI) had a higher in-hospital mortality than patients with risk factors, researchers wrote in the European Heart Journal.
They said the term 'SMuRF-less' was recently coined to stress the need for further research on cardiovascular outcomes in this group who did not have the standard risk factors of diabetes, dyslipidaemia, hypertension, and smoking.
To explore the long-term outcomes of SMuRF-less patients with stable CAD, the researchers analysed data from CLARIFY, an observational study of 32,703 patients with stable CAD enrolled between 2009 and 2010 in 45 countries in Europe, Asia, America, the Middle East, Australia, and South Africa.
Among 22,132 patients with complete risk factor and outcome information, 977 (4.4%) were classed as SMuRF-less.
Age, sex, and time since CAD diagnosis were similar across groups, the researchers reported.
SMuRF-less patients had a lower five-year rate of cardiovascular death or non-fatal MI than patients with risk factors (5.43% vs 7.68%), researchers reported.
All-cause mortality and major adverse cardiovascular events (cardiovascular death, non-fatal MI, or non-fatal stroke) were also lower in SMuRF-less patients, they found.
Senior author Professor Phillipe Gabriel Steg, professor of cardiology at Université de Paris, France, and colleagues said the risk of adverse cardiovascular outcomes increased steadily with the number of risk factors.
'Standard modifiable cardiovascular risk factor-less status appeared more protective in women than in men,' Professor Steg and co-authors noted.
However, they stressed the study did not question the need for SMuRF-less patients with stable CAD to receive guideline-based therapy, adding that SMuRF-less patients remained at a substantial risk of cardiovascular events.
'While the risk was lower in SMuRF-less patients, they still experience a substantial risk of cardiovascular events; thus efforts should be made to achieve higher rates of implementation of evidence-based therapies,' Professor Steg and colleagues wrote.
The study found SMuRF-less patients were less likely to be prescribed statins, angiotensin-converting enzyme inhibitors/angiotensin II receptor blockers, and beta-blockers.
'It remains crucial to improve the visibility of the SMuRF-less population in future clinical trials and guidelines,' Professor Steg and colleagues concluded.
The previous body of research of SMuRF-less patients had focused on in-hospital mortality after first-presentation MI, with the paradoxical finding that SMuRF-less patients might experience more adverse outcomes after first-presentation MI.
However, the causes of the poor prognosis of SMuRF-less patients in the immediate post-infarction period as reported in previous research were not explored in the present study, the study authors noted.
'SMuRF-less patients may have specific causes of MI (dissection, embolism, spasms, and the use of toxic substances), which can be difficult to manage during the acute phase but are associated with fewer comorbidities,' the researchers suggested.
'Future research efforts should focus on the early post-MI period, when the vulnerability of SMuRF-less patients seems to be at stake.'
The study was funded by pharmaceutical firm Servier, but the authors said the sponsor had no role in the study design or management.
Presenting Symptoms Crucial For Predicting PCI Efficacy For Stable Coronary Artery Disease: ORBITA-2 Analysis
UK: In a groundbreaking study published in the Journal of the American College of Cardiology, researchers have uncovered a significant predictor in determining the efficacy of Percutaneous Coronary Intervention (PCI) in treating Stable Coronary Artery Disease (CAD). The study sheds light on the pivotal role symptom severity plays in accurately assessing the effectiveness of PCI.
The analysis of the ORBITA-2 trial showed that symptom severity and nature were poorly associated with disease severity, however, the nature of symptoms powerfully predicted the placebo-controlled efficacy of PCI.
"Two groups more likely to benefit from PCI for angina relief in stable CAD: those with Rose pattern angina (OR 1.9) and those with guideline-based typical angina (OR 1.8)," the researchers reported.
"Typical angina and rose angina are excellent predictors of the placebo-controlled efficacy of PCI," Florentina Simader, MD, of Imperial College London, said at the annual EuroPCR meeting, while presenting the results.
Stable CAD, characterized by the narrowing of coronary arteries, poses a significant health risk worldwide. PCI, a commonly employed intervention, involves the insertion of a stent to alleviate arterial blockages. However, the efficacy of PCI in improving patient outcomes has remained a subject of debate.
Placebo-controlled evidence from ORBITA-2 showed that PCI in stable coronary artery disease with little or no antianginal medication relieved angina, but residual symptoms persisted in many. There was no clarity on the reason. Considering this, the research team investigated the relationship between presenting symptoms and disease severity (non-invasive, anatomic, and invasive ischemia) and the ability of symptoms to predict the placebo-controlled PCI efficacy in an ORBITA-2 secondary analysis.
For this purpose, the researchers used the ORBITA smartphone application and symptom and quality of life questionnaires including the Rose angina questionnaire to assess the pre-randomization symptom severity and nature. Disease severity was assessed using stress echocardiography, quantitative coronary angiography (QCA), instantaneous wave-free ratio (iFR), and fractional flow reserve (FFR).
The study led to the following findings:
"Whether a person had chest pains resolved by angioplasty hinged on the nature, not the severity, of their presenting symptoms," the researchers concluded.
Reference:
Simader, F. A., Rajkumar, C. A., Foley, M. J., Ahmed-Jushuf, F., Chotai, S., Bual, N., Khokhar, A., Gohar, A., Lampadakis, I., Ganesananthan, S., Pathimagaraj, R. H., Nowbar, A., Davies, J. R., Keeble, T. R., O'Kane, P. D., Haworth, P., Routledge, H., Kotecha, T., Spratt, J. C., . . . Al-Lamee, R. K. (2024). Symptoms as a Predictor of the Placebo-Controlled Efficacy of PCI in Stable Coronary Artery Disease. Journal of the American College of Cardiology. Https://doi.Org/10.1016/j.Jacc.2024.04.016
New Data Reveals Optimal Timing For Percutaneous Coronary Intervention In TAVR Patients
New data reveals that percutaneous coronary intervention (PCI) can be safely performed before, during, or after transcatheter aortic valve replacement (TAVR) for patients with stable coronary artery disease (CAD). The results from the analysis were presented today at the Society for Cardiovascular Angiography & Interventions (SCAI) 2024 Scientific Sessions.
For those with CAD, PCI and TAVR are often required to restore blood flow. Many clinicians prefer to conduct PCI before TAVR due to the potential complications that could occur during the replacement procedure. However, the optimal timing for PCI in patients undergoing TAVR is debatable.
The analysis included 49,344 patients with stable CAD who underwent PCI before (84.7%), after (1.3%), or simultaneously (14%) with TAVR using the Sapien 3 (S3) platform balloon expandable bioprosthesis. The analysis was conducted using the TVT Registry and Medicare linkage between 2015 and 2024.
In a propensity-matched analysis, the composite of all-cause mortality and stroke were similar in three groups at three years of follow-up. The authors noted that due to the small numbers of patients undergoing PCIs after the TAVR, when they compared just the two other groups (before and concomitant PCIs), PCI performed before TAVR had a slight advantage over concomitant PCI with TAVR at three years (P=0.012).
These findings are exciting as they slightly differ from previously published registry data. We believe this data will instill confidence and provide supporting evidence for many physicians and heart teams to make decisions regarding the timing of PCI in patients undergoing TAVR."
Abhijeet Dhoble, MD, MPH, FACC, FSCAI, cardiologist at University of Texas Health Science Center at Houston, and lead author of the study
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