Statins have been shown to be effective in reducing cardiovascular events.Their magnitude of benefits has been proportionate to the reduction in low-density lipoprotein cholesterol(LDL-c).Intensive lipid-lowering ther...Statins have been shown to be effective in reducing cardiovascular events.Their magnitude of benefits has been proportionate to the reduction in low-density lipoprotein cholesterol(LDL-c).Intensive lipid-lowering therapies using ezetimibe and more recently proprotein convertase subtilisin kexin 9 inhibitors have further improved clinical outcomes.Unselective application of these treatments is undesirable and unaffordable and,therefore,has been guided by LDL-c level.Nonetheless,the residual risk in the post-statin era is markedly heterogeneous,including thrombosis and inflammation risks.Moreover,the lipoprotein related risk is increasingly recognised to be related to other non-LDL-c markers such as Lp(a).Emerging data show that intensive lipid-lowering therapy produce larger absolute risk reduction in patients with polyvascular disease,post coronary artery bypass graft and diabetes.Notably,these clinical entities share similar phenotype of large burden of atherosclerotic plaques.Novel plaque imaging may aid decision making by identifying patients with propensity to develop lipid rich plagues at multi-vascular sites.Those patients may be suitable candidates for intensive lipid lowering treatment.展开更多
BACKGROUND Coexistent coronary artery disease is commonly seen in patients undergoing transcatheter aortic valve implantation(TAVI).Previous studies showed that pre-TAVI coronary revascularisation was not associated w...BACKGROUND Coexistent coronary artery disease is commonly seen in patients undergoing transcatheter aortic valve implantation(TAVI).Previous studies showed that pre-TAVI coronary revascularisation was not associated with improved outcomes,challenging the clinical value of routine coronary angiogram(CA).AIM To assess whether a selective approach to perform pre-TAVI CA is safe and feasible.METHODS This was a retrospective non-randomised single-centre analysis of consecutive patients undergoing TAVI.A selective approach for performing CA tailored to patient clinical need was developed.Clinical outcomes were compared based on whether patients underwent CA.The primary endpoint was a composite of allcause mortality,myocardial infraction,repeat CA,and re-admission with heart failure.RESULTS Of 348 patients(average age 81±7 and 57%male)were included with a median follow up of 19(9-31)mo.One hundred and fifty-four(44%)patients,underwent CA before TAVI procedure.Patients who underwent CA were more likely to have previous myocardial infarction(MI)and previous percutaneous revascularisation.The primary endpoint was comparable between the two group(22.6%vs 22.2%;hazard ratio 1.05,95%CI:0.67-1.64,P=0.82).Patients who had CA were less likely to be readmitted with heart failure(P=0.022),but more likely to have repeat CA(P=0.002)and MI(P=0.007).In those who underwent CA,the presence of flow limiting lesions did not affect the incidence of primary endpoint,or its components,except for increased rate of repeat CA.CONCLUSION Selective CA is a feasible and safe approach.The clinical value of routine CA should be challenged in future randomised trials.展开更多
文摘Statins have been shown to be effective in reducing cardiovascular events.Their magnitude of benefits has been proportionate to the reduction in low-density lipoprotein cholesterol(LDL-c).Intensive lipid-lowering therapies using ezetimibe and more recently proprotein convertase subtilisin kexin 9 inhibitors have further improved clinical outcomes.Unselective application of these treatments is undesirable and unaffordable and,therefore,has been guided by LDL-c level.Nonetheless,the residual risk in the post-statin era is markedly heterogeneous,including thrombosis and inflammation risks.Moreover,the lipoprotein related risk is increasingly recognised to be related to other non-LDL-c markers such as Lp(a).Emerging data show that intensive lipid-lowering therapy produce larger absolute risk reduction in patients with polyvascular disease,post coronary artery bypass graft and diabetes.Notably,these clinical entities share similar phenotype of large burden of atherosclerotic plaques.Novel plaque imaging may aid decision making by identifying patients with propensity to develop lipid rich plagues at multi-vascular sites.Those patients may be suitable candidates for intensive lipid lowering treatment.
文摘BACKGROUND Coexistent coronary artery disease is commonly seen in patients undergoing transcatheter aortic valve implantation(TAVI).Previous studies showed that pre-TAVI coronary revascularisation was not associated with improved outcomes,challenging the clinical value of routine coronary angiogram(CA).AIM To assess whether a selective approach to perform pre-TAVI CA is safe and feasible.METHODS This was a retrospective non-randomised single-centre analysis of consecutive patients undergoing TAVI.A selective approach for performing CA tailored to patient clinical need was developed.Clinical outcomes were compared based on whether patients underwent CA.The primary endpoint was a composite of allcause mortality,myocardial infraction,repeat CA,and re-admission with heart failure.RESULTS Of 348 patients(average age 81±7 and 57%male)were included with a median follow up of 19(9-31)mo.One hundred and fifty-four(44%)patients,underwent CA before TAVI procedure.Patients who underwent CA were more likely to have previous myocardial infarction(MI)and previous percutaneous revascularisation.The primary endpoint was comparable between the two group(22.6%vs 22.2%;hazard ratio 1.05,95%CI:0.67-1.64,P=0.82).Patients who had CA were less likely to be readmitted with heart failure(P=0.022),but more likely to have repeat CA(P=0.002)and MI(P=0.007).In those who underwent CA,the presence of flow limiting lesions did not affect the incidence of primary endpoint,or its components,except for increased rate of repeat CA.CONCLUSION Selective CA is a feasible and safe approach.The clinical value of routine CA should be challenged in future randomised trials.
