Akman, Zafer

Background Older adults undergoing percutaneous coronary intervention (PCI) face unique challenges due to complex anatomy and comorbidities. Intravascular imaging [including intravascular ultrasound (IVUS) and optical coherence tomography (OCT)] has been shown to improve PCI outcomes, but its benefits in older adults are less well established. We conducted a meta-analysis of randomized controlled trials (RCTs) to compare intravascular imaging with angiography alone to guide PCI in older adults. Methods Cochrane, PubMed, and Scopus were searched for RCTs comparing intravascular imaging (IVUS or OCT) vs. angiography alone in adults aged ≥65 years. The outcome of interest was major adverse cardiovascular events (MACE) at the longest follow-up, as defined by each trial. Subgroup analyses were performed based on intravascular imaging modality, age group, and lesion complexity. Data were pooled using random-effects models, and heterogeneity was assessed using Higgins’ I ² statistic. Results Nine RCTs ( n = 7164, intravascular imaging = 3703, angiography alone = 3461) met the inclusion criteria. Intravascular imaging significantly reduced MACE compared with angiography alone [relative risk (RR) 0.66, 95% confidence interval (CI) 0.56–0.77; P < 0.001; I ² = 0%]. IVUS demonstrated superiority over angiography alone (RR 0.55, 95% CI 0.43–0.72; P < 0.001; I ² = 0%), while OCT demonstrated only a trend toward MACE reduction (RR 0.80, 95% CI 0.62–1.02). Subgroup analyses indicated consistent benefits with intravascular imaging for adults aged ≥65 and ≥70 years, respectively, and among those with complex coronary lesions (RR 0.65, 95% CI 0.53–0.79; P < 0.001). Conclusion Intravascular imaging guidance, especially IVUS, reduces MACE in older adults undergoing PCI compared with angiography alone.

Importance Monoclonal gammopathy of undetermined significance (MGUS) is associated with an increased risk of cardiovascular disease. Glucagon-like peptide-1 (GLP-1) receptor agonists (RAs) have demonstrated cardiorenal benefits in patients with type 2 diabetes, but their effectiveness in patients with MGUS remains unexplored. Objective To assess the effectiveness of GLP-1 RAs for primary prevention of major adverse cardiovascular and cerebrovascular events (MACCE) in patients with MGUS and diabetes. Design, Setting, and Participants This retrospective cohort study used a propensity score–matched analysis of data from the TriNetX Global Database, encompassing patients diagnosed with diabetes and MGUS between January 1, 2018, and January 13, 2023. Patients with prior heart failure (HF), ischemic heart disease, coronary revascularization, or stroke or transient ischemic attack before MGUS diagnosis were excluded. The cohort was divided into 2 groups: GLP-1 RA users and nonusers at baseline. After 1:1 propensity score matching, GLP-1 RA users and nonusers were compared up to 5 years from the MGUS diagnosis date. Data analyses were completed January 19, 2025. Exposure GLP-1 RA use within 1 year before MGUS diagnosis. Main Outcomes and Measures The primary end point was MACCE, defined as a composite of all-cause mortality, new-onset HF, acute coronary syndrome, and stroke or transient ischemic attack. Secondary end points included individual MACCE components, decompensated HF, and acute kidney injury or end-stage kidney disease. Results A total of 4871 patients with MGUS (mean [SD] age, 68.9 [10.1] years; 2366 [48.5%] male) were included (473 GLP-1 RA users and 4398 non-users). A total of 460 users were matched to 460 nonusers, with balanced characteristics (mean [SD] age, 65.0 [10.6] vs 65.1 [11.0] years; 229 [49.7%] male vs 234 [50.8%] male), including 14 patients (3.0%) vs 13 patients (2.8%) identifying as Asian, 8 (21.3%) vs 92 (20.0%) as Black or African American, 25 patients (5.4%) vs 20 patients (4.3%) as Hispanic or Latino, and 243 patients (52.8%) vs 250 patients (54.3%) as White. GLP-1 RA use was associated with a significantly lower risk of MACCE (hazard ratio [HR], 0.75; 95% CI, 0.60-0.93). Significant reductions were also observed in all-cause mortality (HR, 0.57; 95% CI, 0.37-0.87), new-onset HF (HR, 0.69; 95% CI, 0.54-0.90), decompensated HF (HR, 0.60; 95% CI, 0.43-0.84), and acute kidney injury or end-stage kidney disease (HR, 0.73; 95% CI, 0.57-0.92). Conclusions and Relevance The findings of this cohort study of GLP-1 RA use vs no use in patients with MGUS and diabetes suggest the potential of GLP-1 RA for primary prevention of MACCE. These findings warrant further investigation in prospective randomized trials.