Salarifar, Mojtaba

Abstract Background The standard modifiable cardiovascular risk factors (SMuRFs: hypertension, diabetes mellitus, dyslipidemia, and cigarette smoking) are known to play a major role in the pathogenesis of coronary heart disease (CHD). Despite endeavors aiming at primary and secondary prevention of these risk factors, CHD has remained a leading cause of mortality and morbidity worldwide. A considerable proportion of patients admitted with acute coronary syndrome (ACS) have no SMuRFs, the outcomes of whom following percutaneous coronary intervention (PCI) are debated. Further, sex differences within this population have yet to be established. Purpose The present study aimed to evaluate the association between SMuRF-less status and post-PCI outcomes among patients with ACS. Further, we sought to determine possible sex differences in the post-PCI outcomes related to the SMuRF-less status. Methods This retrospective cohort study included 7847 patients with ACS who underwent PCI. The study outcomes were all-cause mortality and major adverse cardio-cerebrovascular events (MACCE). The association between the absence of SMuRFs (SMuRF-less status) and outcomes among all the patients and each sex was assessed using logistic and Cox proportional hazard regressions. A separate landmark analysis with the landmark (cutoff) set at 30 days after the index procedure was performed as well. Models were adjusted for age, sex, body mass index, chronic obstructive pulmonary disease, cerebrovascular accident, previous myocardial infarction, estimated glomerular filtration rate, ejection fraction, and left main disease. Results Approximately 11% of the study population had none of the SMuRFs. The SMuRF-less and SMuRF+ groups aged 63.10 ±8.91 (85.1% males) and 62.53 ± 10.91 years (74.9% males), respectively. During 12.13 [11.99-12.36] months of follow-up, the followings were respective event numbers in the SMuRF-less and SMuRF+ groups: all-cause mortality: 35 (4.1%) and 273 (3.9%); MACCE: 99 (11.6%) and 898 (12.8%). All-cause mortality (adjusted-hazard ratio (HR): 1.01, 95%CI: 0.88-1.46, P: 0.731), and MACCE (adjusted-HR: 0.93, 95%CI:0.81-1.12, P: 0.412) did not differ between patients with and without SMuRFs (Figure 1). Sex-stratified analyses recapitulated similar outcomes between SMuRF+ and SMuRF-less men. In contrast, SMuRF-less women had significantly higher all-cause mortality (adjusted-HR:1.41, 95%CI: 1.02-3.21, P: 0.008) than SMuRF+ women (Figure 1). Notably, following landmark analyses, this significant association among women disappeared (adjusted-HR: 0.99, 95%CI: 0.41-2.59, P:0.991), implying that its significance stemmed, to some extent, from higher 30-day mortality (Figure 1,2). Conclusions Almost one in 10 patients with ACS who underwent PCI had no SMuRFs. The absence of SMuRFs did not confer any benefit in terms of in-hospital mortality, one-year mortality, and MACCE. Even worse, SMuRF-less women paradoxically had an excessive risk of one-year mortality.

AbstractAimAchieving the optimal apposition of coronary stents during percutaneous coronary intervention is not always feasible. The risks and benefits of stent postdilation in primary percutaneous coronary intervention (PPCI) in patients with ST‐elevation myocardial infarction (STEMI) have remained controversial. We sought to evaluate the immediate angiographic and long‐term outcomes in patients with and without stent postdilation.MethodsA cohort of patients (n = 1,224) with STEMI, treated with PPCI (n = 500 postdilated; n = 724 controls), were studied. The flow grade, the myocardial blush grade, and the frame count were considered angiographic outcomes. The clinical outcomes were major adverse cardiovascular events (MACE)—comprising cardiac death, nonfatal MI, and repeat revascularization—and the device‐oriented composite endpoint (DOCE)—consisting of cardiac death, target lesion revascularization, and target vessel revascularization.ResultsThe flow and myocardial blush grades were not different between the two groups, and the frame count was significantly lower in the postdilation group (15.7 ± 8.4 vs. 17 ± 10.4; p < .05). The patients were followed up for 348 ± 399 days. DOCE (2.2% vs. 5.8%) and cardiac mortality (1.2% vs. 3.2%) were lower in the postdilation group. In the fully adjusted propensity score‐matched analysis, postdilation was associated with decreased DOCE (HR = 0.40 [0.18–0.87], p = .021).ConclusionsSelective postdilation improved some angiographic and clinical outcomes and could not be discouraged in PPCI on patients with STEMI.