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Background: In this study, we compared the outcomes of medical therapy (MT) with successful percutaneous coronary intervention (PCI) in chronic total occlusions (CTO) patients with and without type 2 diabetes mellitus., Methods: A total of 2015 patients with CTOs were stratified. Diabetic patients (n = 755, 37.5%) and non-diabetic patients (n = 1260, 62.5%) were subjected to medical therapy or successful CTO-PCI. We performed a propensity score matching (PSM) to balance the baseline characteristics. A comparison of the major adverse cardiac events (MACE) was done to evaluate long-term outcomes., Results: The median follow-up duration was 2.6 years. Through multivariate analysis, the incidence of MACE was significantly higher among diabetic patients compared to the non-diabetic patients (adjusted hazard ratio [HR] 1.32, 95% confidence interval [CI] 1.09-1.61, p = 0.005). Among the diabetic group, the rate of MACE (adjusted HR 0.61, 95% CI 0.42-0.87, p = 0.006) was significantly lower in the successful CTO-PCI group than in the MT group. Besides, in the non-diabetic group, the prevalence of MACE (adjusted HR 0.85, 95% CI 0.64-1.15, p = 0.294) and cardiac death (adjusted HR 0.94, 95% CI 0.51-1.70, p = 0.825) were comparable between the two groups. Similar results as with the early detection were obtained in propensity-matched diabetic and non-diabetic patients. Notably, there was a significant interaction between diabetic or non-diabetic with the therapeutic strategy on MACE (p for interaction = 0.036)., Conclusions: For treatment of CTO, successful CTO-PCI highly reduces the risk of MACE in diabetic patients when compared with medical therapy. However, this does not apply to non-diabetic patients.

Objectives: There are little data on the long-term clinical outcomes of medical therapy (MT) compared with revascularization in patients with chronic total occlusions (CTOs)., Methods: Between January 2007 and December 2016, a total of 1655 patients with ≥1 CTO were enrolled in our center and were divided into the MT group (n = 800) and revascularization group (n = 855) according to the initial treatment strategy. Propensity score matching was also performed to adjust for baseline characteristics. The primary outcome was cardiac death., Results: After 2 years of follow-up, there was no significant difference between the two groups with regard to the prevalence of cardiac death (MT vs. revascularization: 6.6% vs. 4.2%, adjusted hazard ratio [HR] 0.95, 95% confidence interval [CI] 0.60-1.49, p = 0.820). In the propensity-matched population (406 pairs), there were no significant differences in the prevalence of cardiac death (MT vs. revascularization: 5.4% vs. 4.7%, HR 0.88, 95% CI 0.48-1.63, p = 0.694), except for target vessel revascularization (TVR) (0.44, 0.31-0.63, <0.001) and major adverse cardiovascular events (MACE) (0.51, 0.38-0.68, <0.001), between the two groups. There were also no significant differences in the prevalence of cardiac death (MT vs. successful CTO-PCI: 6.6% vs. 4.0%, HR 0.94, 95% CI 0.41-2.15, p = 0.881) between the MT and successful CTO-PCI groups., Conclusion: As an initial management strategy in patients with CTOs, revascularization did not reduce the risk of cardiac death compared with treatment with medical therapy alone. However, revascularization was associated with reduction in the prevalence of TVR and MACE. Furthermore, successful CTO-PCI was also not associated with improved long-term survival compared with MT alone., (Copyright © 2020 Hellenic Society of Cardiology. Published by Elsevier B.V. All rights reserved.)

Purpose: The aim of this study was to explore the safety and efficacy of bivalirudin in elderly patients undergoing percutaneous coronary intervention (PCI)., Methods: An electronic search was conducted for randomized controlled trials with outcomes of interest in the elderly (≥ 65 years of age). Pooled risk ratios (RR) and 95% confidence interval (CI) using random effects Der Simonian-Laird models were calculated. Primary outcomes were net adverse clinical events (NACE) and major bleeding events at 30 days. Secondary outcomes were major adverse cardiac events (MACE) at 30 days. MACE, all-cause mortality, and NACE at 6-12 months were also examined., Results: Eleven trials that randomized a total of 15,895 elderly patients undergoing PCI to bivalirudin versus heparin were included. At 30 days, bivalirudin was associated with a reduced risk of NACE (0.86 [0.75-0.99], p = 0.04), mainly driven by reduction in major bleeding events (0.66 [0.54-0.80], p < 0.0001), as compared with heparin. On subgroup analyses based on the use of GPI in the heparin arm, benefit of major bleeding associated with bivalirudin appeared to be equally evident when GPI was used as a bailout (0.66 [0.46-0.94], p = 0.02) versus routine (0.67 [0.51-0.88], p = 0.004) adjunctive therapy with heparin. Subgroup analyses stratified by clinical presentation showed that benefit of bivalirudin in reducing NACE was even more obvious in the elderly group presenting with ST segment elevation myocardial infarction (STEMI) (0.76 [0.65-0.89], p = 0.0007), as compared with the overall (acute coronary syndrome or stable ischemic heart disease) group. No difference in MACE (0.94 [0.82-1.09], p = 0.42) was demonstrated between the two groups. Bivalirudin was associated with a similar risk of NACE (0.74 [0.39-1.42], p = 0.36) at 6 months and MACE (0.90 [0.68-1.19], p = 0.45) at 6-12 months, while a non-statistically significant trend toward lower all-cause mortality (0.70 [0.47-1.06], p = 0.09) at 1 year., Conclusion: In elderly patients undergoing PCI, bivalirudin was associated with a lower risk of major bleeding events and the magnitude of benefit was not related to the use of GPI and irrespective of clinical presentation. Bivalirudin may reduce the NACE, particularly in elderly patients presenting with STEMI or in the setting of routine GPI use in the heparin arm, while no difference in MACE was demonstrated between the two groups.

Objective. To compare the clinical outcomes associated with successful percutaneous coronary intervention (PCI) versus initial medical therapy (MT) in patients with coronary chronic total occlusions (CTOs). Methods. Between January 2007 and December 2016, a total of 1702 patients with ≥1 CTO were enrolled. Patients who had a failed CTO-PCI were excluded. After exclusion, 1294 patients with 1520 CTOs were divided into the MT group initially (did not undergo a CTO-PCI attempt) ( n  = 800) and successful PCI group ( n  = 494). Propensity-score matching was also performed to adjust for baseline characteristics. The primary outcome was cardiac death. Results. The median overall follow-up duration was 3.6 (IQR, 2.1-5.0) years, there was no significant difference between the two groups with respect to the prevalence of cardiac death (MT vs. successful PCI: 6.6 vs. 3.8%, adjusted hazard ratio [HR] 0.93, 95% confidence interval [CI] 0.41-2.14, p  = .867). In the propensity-matched population (286 pairs), there were no significant differences in the prevalence of cardiac death (MT vs. successful PCI: 5.9% vs. 3.1%, HR 0.51, 95% CI 0.23-1.15, p  = .104) and major adverse cardiovascular events (MACE) (HR 0.76, 95% CI 0.53-1.09, p  = .130) between the two groups. Conclusion. In the treatment of patients with CTOs, successful PCI is not associated with improved long-term cardiovascular survival or reduced the risk of MACE compared with MT alone initially.

Background: There is a paucity of information about the gender differences in clinical outcomes of successful percutaneous coronary intervention (PCI) compared with medical therapy (MT) in patients with coronary chronic total occlusions (CTOs)., Objectives: We aimed to investigate the impact of gender on long-term clinical outcomes associated with successful CTO-PCI versus MT in patients with CTOs., Methods: Between January 2007 and December 2016, a total of 1702 patients with ≥1 CTO were enrolled. After exclusion, 1294 patients with 1520 CTOs were analyzed and were divided into the female group ( n  = 304, 23.5%) and the male group ( n  = 990, 76.5%). The patients in the female or male group were assigned to a MT group or successful CTO-PCI group according to the treatment strategy. In the female group, they were divided into two groups: 177 patients in the MT group and 127 patients in the successful CTO-PCI group. In the male group, they were divided into two groups: 623 patients in the MT group and 367 patients in the successful CTO-PCI group. The primary outcome was cardiac death. The secondary outcome was major adverse cardiac event (MACE)., Results: The median overall follow-up duration was 3.6 (IQR, 2.1-5.0) years, there were no significant differences between the MT and successful CTO-PCI groups with respect to the prevalence of cardiac death (MT vs. successful PCI: 6.8% vs. 3.9%, p =0.287) and MACE (20.9% vs. 21.3%, p =0.810) in female patients. In the male group, the occurrence of cardiac death (MT vs. successful PCI: 6.6% vs. 3.8%, p =0.066) was similar between the two groups. The MACE rate (30.0% vs. 18.5%, p < 0.001) was significantly higher in the MT group. Heart failure (hazard ratio 3.40, 95% confidence interval 1.23-9.40, p =0.018) was an independent predictor of cardiac death in female patients., Conclusions: Successful CTO-PCI was not associated with reduced risk of cardiac death compared with medical therapy alone in both female and male patients. However, men have a significant reduction in MACE rate after successful CTO-PCI. Aggressive CTO-PCI should be considered carefully among female patients., Competing Interests: The authors declare that they have no conflicts of interest., (Copyright © 2019 Lei Guo et al.)