Predictors, Trends, and Outcomes (Among Older Patients ≥65 Years of Age) Associated With Beta-Blocker Use in Patients With Stable Angina Undergoing Elective Percutaneous Coronary Intervention: Insights From the NCDR Registry.

This study sought to examine predictors, trends, and outcomes associated with β-blocker prescriptions at discharge in patients with stable angina without prior history of myocardial infarction (MI) or systolic heart failure (HF) undergoing elective percutaneous coronary intervention (PCI). The benefits of β-blockers in patients with MI and/or systolic HF are well established. However, whether β-blockers affect outcomes in patients with stable angina, especially after PCI, remains uncertain. We included patients with stable angina without prior history of MI, left ventricular systolic dysfunction (left ventricular ejection fraction <40%) or systolic HF undergoing elective PCI between January 2005 and March 2013 from the hospitals enrolled in the National Cardiovascular Data Registry (NCDR) CathPCI registry. These patients were retrospectively analyzed for predictors and trends of β-blocker prescriptions at discharge. All-cause mortality (primary endpoint), revascularization, or hospitalization related to MI, HF, or stroke at 30-day and 3-year follow-up were analyzed among patients ≥65 years of age. A total of 755,215 patients from 1,443 sites were studied, and 71.4% population of our cohort was discharged on β-blockers. At 3-year follow-up among patients ≥65 years of age with CMS data linkage (16.3% of the studied population), there was no difference in adjusted mortality rate (14.0% vs. 13.3%; adjusted hazard ratio [HR]: 1.00; 95% confidence interval [CI]: 0.96 to 1.03; p = 0.84), MI (4.2% vs. 3.9%; adjusted HR: 1.00; 95% CI: 0.93 to 1.07; p = 0.92), stroke (2.3% vs. 2.0%; adjusted HR: 1.08; 95% CI: 0.98 to 1.18; p = 0.14) or revascularization (18.2% vs. 17.8%; adjusted HR: 0.97; 95% CI: 0.94 to 1.01; p = 0.10) with β-blocker prescription. However, discharge on β-blockers was associated with more HF readmissions at 3-year follow-up (8.0% vs. 6.1%; adjusted HR: 1.18; 95% CI: 1.12 to 1.25; p < 0.001). Results at 30-day follow-up were broadly consistent as well. During the period between 2005 and 2013, there was a gradual increase in prescription of β-blockers at the index discharge in our cohort (p < 0.001). Among patients ≥65 years of age with history of stable angina without prior MI, systolic HF or left ventricular ejection fraction <40% undergoing elective PCI, β-blocker use at discharge was not associated with any reduction in cardiovascular morbidity or mortality at 30-day and at 3-year follow-up. Over time, β-blockers use at discharge in this population has continued to increase.

Motivala AA ，Parikh V ，Roe M ，Dai D ，Abbott JD ，Prasad A ，Mukherjee D ... -  《-》

The prevalence, predictors and outcomes of guideline-directed medical therapy in patients with acute myocardial infarction undergoing PCI, an analysis from the PROMETHEUS registry.

To investigate the prevalence, predictors and associations between guideline-directed medical therapy (GDMT) and clinical outcomes in acute myocardial infarction (AMI) patients undergoing percutaneous coronary intervention (PCI) from eight academic centers in the United States. Evidence for GDMT in patients with AMI comes from randomized controlled trials. The use of GDMT in clinical practice is unknown in this setting. PROMETHEUS is a multicenter observational registry comprising 19,914 patients with acute coronary syndrome (ACS) undergoing PCI. Patients with AMI were divided into two groups based on the prescription of GDMT or not (non-GDMT) at discharge. GDMT was defined according to American College of Cardiology/American Heart Association (ACC/AHA) class I recommendations, specifically, dual antiplatelet therapy, statin and beta-blocker for all AMI patients, and additional ACEI/ARB in patients with left ventricular ejection fraction (LVEF) less than 40%, hypertension, diabetes mellitus (DM) or chronic kidney disease (CKD). The primary endpoint was major adverse cardiovascular events (MACE) defined as a composite of all-cause death, MI, stroke or unplanned target vessel revascularization (TVR) at 1 year. Out of 4,834 patients with AMI, 3,356 (69.4%) patients were discharged on GDMT. Patients receiving GDMT were more often younger and male. Compared with non-GDMT patients, GDMT patients had a significantly lower frequency of comorbidities. Predictors of greater GDMT prescription at discharge were ST-segment elevation myocardial infarction (STEMI), and increased body mass index (BMI), whereas hypertension, prior PCI, anemia and CKD were associated with less GDMT prescription. At 1 year, the use of GDMT was associated with a significantly lower incidence of MACE (13.7% vs. 22.5%; adjusted HR 0.68; 95%CI 0.58-0.80; P < 0.001), death (3.7% vs. 9.4%; adjusted HR 0.61; 95%CI 0.46-0.80; P < 0.001), and unplanned TVR (8.4% vs. 11.3%; adjusted HR 0.76; 95%CI 0.61-0.96; P = 0.020). However, there were no significant differences in the incidence of MI (4.3% vs. 7.0%; adjusted HR 0.75; 95%CI 0.56-1.01; P = 0.056), stroke (1.5% vs. 2.0%; adjusted HR 0.79; 95%CI 0.47-1.34; P = 0.384) between the two groups. In a contemporary practice setting in the United States, GDMT was utilized in just over two-thirds of AMI patients undergoing PCI. Predictors of GDMT prescription at discharge included STEMI, BMI and absence of hypertension, CKD, anemia or prior PCI. Use of GDMT was associated with significantly lower risk of 1-year MACE and mortality.

Ge Z ，Baber U ，Claessen BE ，Farhan S ，Chandrasekhar J ，Li SX ，Sartori S ，Kini AS ，Rao SV ，Weiss S ，Henry TD ，Vogel B ，Sorrentino S ，Faggioni M ，Kapadia S ，Muhlestein B ，Strauss C ，Toma C ，DeFranco A ，Effron MB ，Keller S ，Baker BA ，Pocock S ，Dangas G ，Mehran R ... -  《-》

Revascularization Trends in Patients With Diabetes Mellitus and Multivessel Coronary Artery Disease Presenting With Non-ST Elevation Myocardial Infarction: Insights From the National Cardiovascular Data Registry Acute Coronary Treatment and Intervention O

Current guidelines recommend surgical revascularization (coronary artery bypass graft [CABG]) over percutaneous coronary intervention (PCI) in patients with diabetes mellitus and multivessel coronary artery disease. Few data are available describing revascularization patterns among these patients in the setting of non-ST-segment-elevation myocardial infarction. Using Acute Coronary Treatment and Intervention Outcomes Network Registry-Get with the Guidelines (ACTION Registry-GWTG), we compared the in-hospital use of different revascularization strategies (PCI versus CABG versus no revascularization) in diabetes mellitus patients with non-ST-segment-elevation myocardial infarction who had angiography, demonstrating multivessel coronary artery disease between July 2008 and December 2014. Factors associated with use of CABG versus PCI were identified using logistic multivariable regression analyses. A total of 29 769 patients from 539 hospitals were included in the study, of which 10 852 (36.4%) were treated with CABG, 13 760 (46.2%) were treated with PCI, and 5157 (17.3%) were treated without revascularization. The overall use of revascularization increased over the study period with an increase in the proportion undergoing PCI (45% to 48.9%; Ptrend=0.0002) and no change in the proportion undergoing CABG (36.1% to 34.7%; ptrend=0.88). There was significant variability between participating hospitals in the use of PCI and CABG (range: 22%-100%; 0%-78%, respectively; P value <0.0001 for both). Patient-level, but not hospital-level, characteristics were statistically associated with the use of PCI versus CABG, including anatomic severity of the disease, early treatment of adenosine diphosphate receptor antagonists at presentation, older age, female sex, and history of heart failure. Among patients with diabetes mellitus and multivessel coronary artery disease presenting with non-ST-segment-elevation myocardial infarction, only one third undergo CABG during the index admission. Furthermore, the use of PCI, but not CABG, increased modestly over the past 6 years.

Pandey A ，McGuire DK ，de Lemos JA ，Das SR ，Berry JD ，Brilakis ES ，Banerjee S ，Marso SP ，Barsness GW ，Simon DN ，Roe M ，Goyal A ，Kosiborod M ，Amsterdam EA ，Kumbhani DJ ... -  《Circulation-Cardiovascular Quality and Outcomes》

β-blocker use in patients after percutaneous coronary interventions: one size fits all? Worse outcomes in patients without myocardial infarction or heart failure.

The influence of β-blocker therapy on prognosis in patients with coronary artery disease (CAD) who underwent percutaneous coronary intervention (PCI) has not been fully explored. We identified 5288 CAD patients who did not have myocardial infarction (MI) or heart failure (HF) but underwent PCI from a large multi-center registry enrolling consecutive patients undergoing first coronary revascularization from 2005 to 2007. The primary outcome was a composite endpoint of cardiac death and/or MI (cardiac death/MI) at 3 years after hospital discharge for PCI. β-blockers were prescribed in 1117 patients (β group, 21.1%) at discharge, while 4171 patients did not (no-β group, 78.9%). Patients in the β group more often had hypertension, multivessel disease, use of statin and angiotensin-converting enzyme inhibitors/angiotensin receptor blockers, but less often had chronic obstructive pulmonary disease. The 3-year incidence of cardiac death/MI was higher in the β group (4.9% vs. 3.4%, log-rank p=0.02). After adjusting for potential confounders, β-blocker therapy was associated with significantly increased risk for cardiac death/MI (hazard ratio 1.48, 95% confidence interval 1.05-2.10, p=0.02). β-blocker therapy was associated with worse 3-year clinical outcomes in CAD patients who underwent PCI but had no history of MI or HF. Randomized trials are warranted to identify appropriate subsets of patients who could truly benefit from long-term use of β-blockers in this setting.

Ozasa N ，Morimoto T ，Bao B ，Furukawa Y ，Nakagawa Y ，Kadota K ，Iwabuchi M ，Shizuta S ，Shiomi H ，Tazaki J ，Natsuaki M ，Kimura T ，CREDO-Kyoto Registry Investigators ... -  《-》

Successful versus unsuccessful antegrade recanalization of single chronic coronary occlusion: eight-year experience and outcomes by a propensity score ascertainment.

The effectiveness of revascularization of chronic total occlusion (CTO) remains intriguing. Thus, we sought to investigate whether a successful PCI for single CTO improves outcomes in a setting of stable angina and chronic occlusion of single coronary artery. Of 11 957 consecutive patients referred for nonurgent PCI between 2003 and 2010, 1110 displayed single CTO and were enrolled to the central CTO-registry database. The primary end-point included all-cause mortality, the secondary end-point a composite of safety outcome measure of all-cause death, nonfatal-MI, the need for urgent revascularization and stroke. The major adverse cardiovascular event (MACE) records were extracted from the national administrative database and all patients were linked to the long-term follow-up. Since the patient assignment was not random, we performed the propensity scoring to minimize selection bias; 734 patients (66%) had a successful PCI-CTO. Compared with successful procedures, unsuccessful procedures had similar rates of all-cause death both in crude (HR, 0.78; 95%CI, 0.49-1.25; P = 0.30) and adjusted analysis (HR, 0.80; 95%CI, 0.50-1.28; P = 0.34). A similar, significant reduction in overall MACE was noted with successful PCI-CTO compared with unsuccessful procedure in unadjusted (HR, 0.74; 95%CI, 0.56-0.96; P = 0.020) and adjusted calculation (HR, 0.73; 95%CI, 0.56-0.96; P = 0.019). Patients after successful PCI-CTO as compared with failed recanalization less frequently underwent surgical revascularization. The benefit was sustained at 3 years follow-up. Successful PCI for single CTO does not improve long-term survival, nonetheless, is associated with reduced overall MACE and the need for surgical revascularization.

Jaguszewski M ，Ciecwierz D ，Gilis-Malinowska N ，Fijalkowski M ，Targonski R ，Masiewicz E ，Strozyk A ，Duda M ，Chmielecki M ，Lewicki L ，Dubaniewicz W ，Burakowski S ，Drewla P ，Skarzynski P ，Rynkiewicz A ，Alibegovic J ，Landmesser U ，Gruchala M ... -  《-》