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Chronic total occlusions are considered the most complex coronary lesion in interventional cardiology. The absence of visible lumen on angiography obscures the vessel course and makes vessel wiring unlikely with conventional techniques. Often a source of severe ischemia, chronic occlusions are also markers of advanced atherosclerosis that brings other complex features including lesion length, bifurcations, calcification, adverse vessel remodelling, distal disease, and anatomic distortion from previous bypass grafting. Often advanced atherosclerosis is associated with patient characteristics like left ventricular dysfunction, previous coronary bypass surgery, or multivessel disease that increase procedural demands and hazards. To accommodate these challenges new techniques and dedicated technologies have been developed. When applied to appropriate patients, these advances have improved procedural success, safety, and outcomes. Our aim is to provide the general cardiologist with an overview of these advances that can serve as a basis for counselling patients considered for revascularization., (Copyright © 2020 Canadian Cardiovascular Society. Published by Elsevier Inc. All rights reserved.)

Background: We aimed to investigate the procedural and long-term outcomes of percutaneous coronary intervention (PCI) for chronic total occlusion (CTO) in patients who had undergone previous coronary artery bypass grafting (CABG) vs those who had not, and to evaluate the role of the Registry of CrossBoss and Hybrid procedures in France, the Netherlands, Belgium, and United Kingdom (RECHARGE) score in predicting acute and long-term outcomes., Methods: We compiled a multicentre registry of consecutive patients undergoing CTO PCI at 7 centres between January 2009 and April 2017. The primary end point was target-vessel failure (TVF), a composite of cardiac death, target-vessel myocardial infarction, and target-vessel revascularization on follow-up., Results: Overall, 2058 patients were included (patients who underwent CABG, n = 401; CABG-naïve patients, n = 1657). Patients who had undergone CABG were older and had a higher prevalence of comorbidities and higher occlusion complexity (RECHARGE score, 3.6 ± 1.3 vs 1.8 ± 1.2; P < 0.001). Antegrade dissection/re-entry techniques and the retrograde approach were used more frequently in patients who had undergone CABG. Procedural metrics were worse, and technical (82% vs 88%; P = 0.001) and procedural (81% vs 87%; P = 0.001) success was lower in patients who had undergone CABG. They also experienced a higher rate of major complications (3.7% vs 1.5%; P = 0.004). The RECHARGE score was inversely associated with technical success (P < 0.001). Median follow-up was 377 days (interquartile range, 277-766 days). The 24-month TVF rate was higher in patients who had undergone CABG than in CABG-naïve patients (16.1% vs 9.0%; P < 0.001). On multivariable analysis, the RECHARGE score (hazard ratio, 1.61; P < 0.001) remained an independent predictor of TVF, together with longer total stent length and not using a drug-eluting stent., Conclusions: Compared with CABG-naïve patients, CTO PCI in patients who had undergone CABG shows higher procedural complexity, worse success rates, and higher adjusted risk of TVF on follow-up., (Copyright © 2018. Published by Elsevier Inc.)

Background: Data on the impact of coronary chronic total occlusion (CTO) percutaneous coronary intervention (PCI) on quality of life (QOL) are limited. To date, studies have been limited in sample size and have focused on only a few domains of the Seattle Angina Questionnaire (SAQ). We evaluated the relationship between coronary CTO PCI and QOL in patients with symptoms of angina, incorporating all aspects of the SAQ., Methods: The SAQ was used to interrogate patients at baseline and at 12 months after CTO PCI. The primary end point was improvement in SAQ scores., Results: A total of 184 patients answered the baseline SAQ. One hundred twenty-two patients answered both questionnaires. SAQ responders were more likely to be men, more like to be in stable medical condition, and more likely to have undergone a successful procedure. We observed statistically significant improvement (P < 0.0001) in physical limitation (mean difference [MD], +27; 95% confidence interval [CI], +23 to +32), angina stability (MD, +16; 95% CI, +10 to +21), angina frequency (MD, +27; 95% CI, +22 to +32), treatment satisfaction (MD, +10; 95% CI, +6 to +13), and QOL domains (MD, +28; 95% CI, +24 to +32). Patients with coronary artery bypass grafting, dissection re-entry techniques, and high complexity (Japanese CTO [J-CTO] ≥ 3) had a similar degree of improvement when compared with their counterparts., Conclusions: CTO PCI is associated with a significant improvement in QOL at 12 months. Patients with complex CTOs derive benefits similar to those in patients with less complex CTOs., (Copyright © 2017 Canadian Cardiovascular Society. Published by Elsevier Inc. All rights reserved.)

Background: Hospitals treating patients with ST-elevation myocardial infarction (STEMI) may show good results with reperfusion treatment (fibrinolysis or primary percutaneous coronary intervention [PPCI]), but a comprehensive evaluation should factor in outcomes of patients with STEMI who do not receive reperfusion. We compared outcomes of patients receiving and not receiving reperfusion within a complete system of STEMI care by hospital type: PPCI centres, fibrinolysis centres, centres that only transfer for PPCI, and centres providing a mix of fibrinolysis and PPCI transfer., Methods: All patients presenting to 82 Quebec hospitals with characteristic symptoms, a final diagnosis of acute myocardial infarction, and core-laboratory confirmed STEMI over two 6-month periods were studied., Results: Of the total 3731 patients with STEMI, 2918 (78.2%) received reperfusion treatment (81% PPCI, 19% fibrinolysis); 813 (21.8%) did not. For reperfusion-treated patients, 30-day mortality was 5.4% in PPCI centres, 5.4% in fibrinolysis centres, 6.9% in transfer PPCI centres, and 6.0% in mixed centres (P = 0.55). For untreated patients, 30-day mortality was 15.7% (PPCI centres), 16.1% (fibrinolysis centres), 21.8% (transfer PPCI), and 24.6% (mixed) (P = 0.08). Adjusted mortality odds ratios for all patients were 1.00 (PPCI centres), 1.50 (95% CI: 0.97-2.32; fibrinolysis centres), 1.30 (0.95-1.78; transfer PPCI centres), and 1.58 (1.09-2.29; mixed centres). PPCI was within recommended delays in 35.4%, 11.9%, and 1.2% of PPCI, transfer, and mixed centres, respectively., Conclusions: Mixed centres had the highest crude and adjusted all-patient 30-day STEMI mortality. Relatively good outcomes of reperfusion-treated patients, despite long treatment delays, can misrepresent overall performance if untreated patients are not examined., (Copyright © 2016 Canadian Cardiovascular Society. Published by Elsevier Inc. All rights reserved.)

Background: Very few data exist on the long-term follow-up of patients with intermediate nonobstructive saphenous vein graft (SVG) lesions. The purpose of this study was to evaluate the 5-year clinical outcomes of the patients enrolled in the Moderate Vein Graft Lesion Stenting With the Taxus Stent and Intravascular Ultrasound (VELETI) and the factors associated with SVG disease progression and outcomes., Methods: Patients with ≥ 1 intermediate SVG lesion (30%-60% diameter stenosis) were randomized to either stenting the SVG lesion with a paclitaxel-eluting stent (PES group, n = 30) or to medical treatment alone (MT group, n = 27). All patients were followed yearly up to 5 years., Results: Major adverse cardiac events (MACEs) (cardiac death, myocardial infarction [MI], revascularization) related to the target SVG lesion tended to be lower in the PES group (17% vs 33%; P = 0.146) due to a lower lesion revascularization rate (13% vs 33%; P = 0.072), with no difference in cardiac death or MI between groups. MACEs related to the target SVG and global MACEs were similar between groups (P > 0.20 for both). A higher cholesterol level at baseline was the only independent predictive factor of MACEs related to the target SVG (P = 0.016)., Conclusions: Over a 5-year period, one third of intermediate lesions in old SVGs progressed, leading to a cardiac event. Stenting these lesions with PESs tended to improve clinical outcomes by reducing lesion progression but not SVG failure. Higher cholesterol levels were associated with SVG disease progression and clinical events. This pilot study provides the basis for a larger trial to determine the efficacy of intermediate SVG lesion plaque sealing., (Copyright © 2014 Canadian Cardiovascular Society. Published by Elsevier Inc. All rights reserved.)

Background: The evaluation of care and the surveillance of disease are important in respect to cardiovascular disease because it is prevalent and costly. In Canada, medico-administrative hospital data are readily available, continuously updated, and offer comprehensive coverage of the patient population. However, there is concern about the quality of the information., Methods: The reliability and predictive capability of comorbidity data contained within Québec's hospital discharge database were assessed in comparison with data collected by clinical medical record reabstraction in a sample of 1989 patients hospitalized from 2002 to 2006 in a mix of 13 hospitals. Patients either had a principal diagnosis of myocardial infarction or underwent angioplasty or bypass surgery. Twenty-one comorbidities included in the Charlson comorbidity index or known to be associated with mortality were validated via medical record reabstraction., Results: Of 14 comorbidities with > 2% prevalence, 8 had excellent agreement with medical record review (κ > 0.8) while 6 had substantial agreement (κ > 0.6). In general, positive predictive values were high, while measures of sensitivity were more variable. Univariate associations between comorbidities and 30-day and 1-year mortality were generally similar in the 2 data sources. Comorbidities retained in the final multivariate stepwise regression models from each data source were almost identical, as were the 2 models' abilities to predict mortality., Conclusions: Hospital discharge data in Québec are, in general, reliably coded and compare favourably with clinical medical record review in their ability to predict mortality. It appears sufficiently reliable to provide useful information about clinical outcomes of cardiac care and to identify problems that warrant investigation., (Copyright © 2012 Canadian Cardiovascular Society. Published by Elsevier Inc. All rights reserved.)

Background: Socioeconomic status (SES) and area of residence are known to impact access to invasive cardiac procedures. Low SES adversely affects long-term mortality after acute myocardial infarction (AMI). Most of the data were derived from private healthcare systems. Our objectives were to evaluate the effects of SES and area of residence on access to coronary angiography, revascularization and mortality after a first AMI in a publicly-funded healthcare system with a high supply of catheterization facilities., Methods: Québec administrative databases were used to identify all patients with a first AMI between 1997 and 2001. The SES was determined with the population deprivation index, which has 2 dimensions: material and social. Six-month access to angiography, revascularization and 1-year mortality were considered in proportional hazards survival regression analyses measuring the effect of deprivation and the geographical area of residence, accounting for several other covariates., Results: The study cohort consisted of 50,242 patients. The most materially and socially deprived patients had a 16% (95% confidence interval [CI], 1.08-1.25) and 13% (95% CI, 1.05-1.21) relative increased hazard of dying within 1 year respectively compared with the most privileged subjects. This mortality gradient could not be explained by meaningful differences in access to angiography or revascularization. Geography did not influence access to revascularization procedures., Conclusions: Despite universal healthcare system, SES measured with a material and social deprivation index, had significant adverse effect on 1-year mortality after a first AMI. Such findings were not explained by lower access to coronary angiography or revascularization., (Copyright © 2012 Canadian Cardiovascular Society. Published by Elsevier Inc. All rights reserved.)

Background: The Clopidogrel for High Atherothrombotic Risk and Ischemic Stabilization, Management, and Avoidance (CHARISMA) trial found a statistically significant reduction in cardiovascular events when clopidogrel was added to aspirin in a prespecified subgroup of patients with established cardiovascular disease. However, the economic implications of such a strategy for the Canadian health care system are unknown., Methods: For each patient in the CHARISMA trial with established cardiovascular disease, costs were estimated by multiplying resource utilization by unit costs derived from populations of Canadian patients in 2008 dollars. Changes in life expectancy due to nonfatal events were estimated with parametric regression models based on the Saskatchewan Health database., Results: For patients with established cardiovascular disease, a strategy of clopidogrel plus aspirin for median duration of 28 months was associated with a 12.5% relative reduction in cardiovascular death, myocardial infarction, or stroke compared with aspirin alone (6.9% vs 7.9%, P =.048). Mean cost per patient was CAD$1,488 higher for clopidogrel plus aspirin, and life expectancy increased by 0.057 years. The resulting incremental cost-effectiveness ratio for adding clopidogrel was CAD$25,969 per life-year gained or CAD$21,549 per quality-adjusted life-year. These results were sensitive to the cost of clopidogrel but relatively insensitive to plausible variations in discount rate, costs other than clopidogrel, and the prognostic impact of nonfatal events., Conclusion: Among the subgroup of patients with established cardiovascular disease in the CHARISMA trial, adding clopidogrel to aspirin increases life expectancy at a cost generally considered acceptable in Canada., (Copyright © 2011. Published by Elsevier Inc.)

Background: Previous randomized controlled trials and meta-analyses demonstrated the superior efficacy of enoxaparin (ENOX) over unfractionated heparin (UFH) in patients with ST segment elevation myocardial infarction (STEMI). The external validity of randomized controlled trials may be limited by selective inclusion of patients who are younger and healthier than the 'real-life' population., Objective: To evaluate the safety and effectiveness of ENOX compared with UFH in unselected STEMI patients., Methods: The safety and effectiveness of ENOX and UFH were compared in STEMI patients who received fibrinolytic therapy at 17 Quebec hospitals in 2003., Results: A total of 498 STEMI patients received systemic anticoagulation, with ENOX and UFH administered in 114 and 384 patients, respectively. There were no differences in baseline characteristics between the two patient groups. The rates of in-hospital major adverse cardiac or cerebral events were 11.4% in the ENOX group compared with 14.0% in the UFH group (P=0.51). In-hospital death or nonfatal reinfarction occurred in 7.9% of patients who received ENOX compared with 9.9% of patients who received UFH (P=0.52). Major bleeding occurred in 4.4% of patients who received ENOX versus 6.0% in patients who received UFH (P=0.51)., Interpretation: There was no significant difference in the rates of in-hospital adverse events in the ENOX group compared with the UFH group, when used in the real-life context. Larger observational studies may further confirm the safety, effectiveness and optimal duration of the administration of ENOX in unselected STEMI patients treated with fibrinolysis.

Introduction: Several meta-analyses have examined the efficacy of smoking cessation therapies in the general population. However, little is known about the efficacy of these therapies in cardiac patients. Therefore, a meta-analysis of randomized controlled trials (RCTs) was performed to determine the efficacy of behavioural therapy and pharmacotherapy for smoking cessation in cardiac patients., Methods: The medical literature was systematically reviewed to identify smoking cessation RCTs in cardiac patients. Only RCTs that reported smoking abstinence at six or 12 months were included. Smoking abstinence was examined based on the 'most rigorous criterion', defined as the most conservative outcome reported in any given RCT., Results: Eleven behavioural therapy RCTs that enrolled 2105 patients and four pharmacotherapy RCTs that enrolled 1542 patients were identified. RCTs differed in the type of behavioural therapy administered as well as the total length and duration of the intervention. RCTs differed in the type of pharmacotherapy administered (one nicotine patch RCT, one nicotine gum RCT and two bupropion RCTs). Behavioural therapy was associated with a significantly higher proportion of smoking abstinence than usual care (OR 1.97 [95% CI 1.37 to 2.85]). Pharmacotherapies were more efficacious than placebo (pooled OR 1.72 [95% CI 1.15 to 2.57])., Conclusions: Both behavioural therapy and pharmacotherapy are more efficacious than usual care for smoking cessation in cardiac patients. The present meta-analysis highlights the need for head-to-head RCTs to identify which smoking cessation therapy is preferred in cardiac patients as well as RCTs examining the efficacy of combined behavioural and pharmacotherapies.

Background: The number of patients with coronary artery disease and type 2 diabetes will increase dramatically over the next decade. Diabetes has been related to accelerated atherosclerosis and many patients with diabetes will require coronary artery bypass graft (CABG) surgery utilizing saphenous vein grafts. After CABG, accelerated atherosclerosis in saphenous vein grafts leads to graft failure in approximately 50% of cases over a 10-year period. Rosiglitazone, a peroxisome proliferator-activated receptor-gamma agonist, has been shown to improve multiple metabolic parameters in patients with type 2 diabetes. However, its role in the prevention of atherosclerosis progression is uncertain., Study Design: VeIn-Coronary aTherOsclerosis and Rosiglitazone after bypass surgerY (VICTORY) is a cardiometabolic trial in which patients with type 2 diabetes, one to 10 years after CABG, will be randomly assigned to receive rosiglitazone (up to 8 mg/day) or a placebo after qualifying angiography and intravascular ultrasound of a segment of one vein graft with or without a native anastomosed coronary artery. A comprehensive set of athero-thrombo-inflammatory markers will be serially assessed during the 12-month follow-up period. Body fat distribution and body composition will be assessed by computed tomography and dual energy x-ray absorptiometry, respectively, at baseline, six months and 12 months follow-up. For atherosclerosis progression evaluation, repeat angiography and intravascular ultrasound will be performed after 12 months follow-up. The primary end point of the study will be the change in atherosclerotic plaque volume in a 40 mm or longer segment of one vein graft., Conclusions: The VICTORY trial is the first cardiometabolic study to evaluate the antiatherosclerotic and metabolic effects of rosiglitazone in post-CABG patients with type 2 diabetes.