The future of interventional cardiology

The sex-based differences in approach and mortality in the management of patients with acute coronary syndrome (ACS) have been known for a while now. Back in 1991 the New England Journal of Medicine published an editorial1 on this matter. In this article Healy coined the term “the Yentl Syndrome” to refer to the invisibility of women in the studies of cardiovascular disease. She argued that women should behave according to the masculine clinical standards to receive the same care; otherwise they were misdiagnosed and mistreated resulting in healthcare of a lower quality and effectiveness.

Over the last few decades, cardiovascular mortality has decreased thanks to the advances made in the prevention, diagnosis, and treatment of ischemic heart disease. This improvement has benefited women as well. According to the RESCATE II registry,2 between 1992 and 2003, in-hospital mortality after a first acute myocardial infarction decreased 25% in women. In spite of this, unlike what happens with males, circulatory system diseases are still the leading cause of mortality among women.3 In the study presented by Anguita et al.4 in the last European Congress of Cardiology, female sex was still an independent predictor factor of mortality in ST-segment elevation acute myocardial infarction (STEMI) in Spain. In this study, the authors retrospectively analyzed the Minimum Basic Data Set of the Spanish Ministry of Health from 2005 through 2015. They identified 325 017 patients with STEMI of whom 38.8% were women, and concluded that in-hospital adjusted mortality is still high in this group. It should be mentioned that odds ratio dropped from 1.28 in 2006 to 1.14 in 2014, which may indicative of better care to women with STEMI.

The article by Tomassini et al.5 recently published on REC: Interventional Cardiology is an in-depth analysis of primary angioplasty and midand long-term mortality in patients with STEMI based on sex differences. It is a retrospective analysis of all patients with STEMI presenting with < 12 h of chest pain who underwent a primary angioplasty at their center from March 2006 to December 2016; in total, 1981 patients (24.4%, women). According to other registries,6 compared to males, women are older (mean age 71.3 ± 11.6 vs 62.9 ± 11.8 years), have a higher prevalence of traditional cardiovascular risk factors, longer total ischemic times, and worse Killip functional class at admission. Oddly enough after matched propensity score analysis, with the same percentage of multivessel coronary artery disease (5.3% vs 4.7%) and stent implantation (82.9% vs 83.9%), the success of the procedure and ST-segment resolution were significantly lower in women (90.2% vs 94.4% and 47.5% vs 54.1%, respectively). The authors suggest that this is probably due to the different pathophysiology of acute myocardial infarction in women, but they do not say anything about the time elapsed from the first medical contact until guidewire crossing or subsequent medical therapy, variables that have a direct impact on the prognosis of patients.

As interventional cardiologists we have a hard time thinking that there may be different system delays because when the infarction code goes off, the most important thing is to find the ST-segment elevation on the EKG, the timeline of disease progression, and the patient’s clinical signs and hemodynamic status (not always in this order). In any case, we should not forget that treatment starts before and after our intervention.

A study conducted in Portugal7 revealed that delays from the first medical contact to radial access were 15 minutes longer among women. This is not an isolated datum. Huded et al.8 analyzed variability during management and the results of the STEMI care network from Cleveland Clinic (Ohio, United States). They observed worse quality of care in women, longer door-to-balloon times, and medical therapies inconsistent with the guidelines in a higher percentage of cases. The implementation of an adapted protocol improved these parameters, especially among women (the percentage of women who received medical therapy as recommended by the guidelines rose to 98%, and system delays were reduced in 20 minutes). Overall, in-hospital mortality decreased 43%. This makes us think that maybe the variability seen in the management of STEMI is something generalized, that the reduction of discrepancies is possible, and that it can reflect the quality and maturity of care networks.

It is noteworthy to discuss the atypical nature of symptoms in women as the cause for these delays. The VIRGO clinical trial9 interviewed 2009 women and 976 males between 18 and 56 years of age admitted due to an STEMI. In both groups, the main symptom was chest pain defined as pain, pressure, tension or discomfort (87% vs 89.5%). Also, women had more accompanying symptoms (58.5% showed more than 3 additional symptoms compared to 46.2% of males). These data are reproduced in another prospective study conducted at an ER that interviewed 1941 patients with suspected ACS. The study confirmed that 92% of women and 91% of males reported chest pain as the main symptom.10 When women were asked why did not they look for help earlier,11 most of them thought it was not an STEMI and they did not want to be called hypochondriacs if it was not serious after all. And they may be right. According to the VIRGO trial, 53% of women who previously sought medical attention were told that it was not an acute coronary event. Maybe as Healy used to say1 women do not belong in the medical and social category of ACS.

For all this, although the management of STEMI in women has improved over the last few decades, articles like Tomassini et al.’s5 are a friendly reminder that there is still work to be done. Not only clinical trials, but also daily gestures like rising the awareness of society and healthcare providers that STEMI affects everyone, women included.

CONFLICTS OF INTEREST

None declared.

REFERENCES

Spain was inducted in the European initiative Stent for Life in a ceremony hosted by the General Assembly of the European Association of Percutaneous Cardiovascular Interventions (EAPCI) back in 2009. As president of the Hemodynamics and Interventional Cardiology Section of the Spanish Society of Cardiology (SEC), Dr. Fina Mauri signed the declaration of commitment with this initiative aimed to improve the access of patients to reperfusion by the increasing use of primary percutaneous coronary interventions (pPCI) as the optimal treatment in the management of ST-segment elevation myocardial infarction (STEMI).

The Stent for Life initiative was born the previous year (September 2008) as an alliance among the Spanish Society of Cardiology, EAPCI, and Eucomed.1 In Europe the situation of reperfusion in the management of infarction was under discussion. They came to the conclusion that there was a great heterogeneity among the different countries with an overall scarce penetration of pPCI as the treatment of choice.2 These differences were not related to gross domestic product (GDP): countries with relative low GDPs (Czech Republic, Hungary, Slovakia, Slovenia, Poland, Lithuania) performed many more pPCIs per million inhabitants compared to other countries with higher GDPs like Spain.2 For this reason, Spain was among the 6 countries asked to participate in this initiative together with Turkey, France, Greece, Bulgaria, and Serbia. All performed less than 200 pPCIs per million inhabitants (in 2008 only 165 PCIs per million inhabitants were performed in Spain). The objectives established at that time are shown on table 1; they were numerical objectives of implementation and penetration of this technique in the management of STEMI with the implicit creation of acute myocardial infarction networks.

Table 1. Objectives of the Stent for Life initiative from 2008

Back in 2008, there were only 4 well-structured infarction networks across in Spain: Murcia, Galicia, Balearic Islands, and the Chartered Community of Navarre performed between 200 and almost 400 pPCIs per million inhabitants. However, eventually only 12.8% of the entire Spanish population benefited from these 4 networks. In the remaining autonomous communities, the pPCIs were performed erratically with numbers lower or closer to 100 pPCIs per million inhabitants. Regions like the Community of Valencia, the Principality of Asturias, and Andalusia performed 61, 78, and 106 pPCIs per million inhabitants).3 Like Europe, these regional differences were not related to the GDP of the different Spanish autonomous communities. Therefore, the creation of a myocardial infarction network with full hospital infrastructure, trained professionals, and a system of medical emergencies in a developed country like ours became a purely organizational matter. In October 2010 and with the explicit support from the SEC and its affiliate sections Hemodynamics and Interventional Cardiology, Ischemic Heart Disease, and Coronary Units the different scientific societies of the autonomous communities signed the declaration of membership to the Stent for Life initiative (figure 1). From that moment on, the focus was on 3 different levels for the progressive and gradual implementation of infarction networks. In the first place, there was a political and media approach to the different health administrations involved. The publication of the comparative results from the different autonomous communities in the media (figure 2) contributed effectively to their involvement in this issue. Parallel to this and thanks to scientific publications and cardiology meetings, professionals became aware on the clinical need to implement these infarction networks.4^-7 Finally, patients were approached through commercial campaigns and media announcements with positive short-term results.8 Everything was mostly funded with the unconditional support from the industry. After 10 years of many people working for the Stent for Life initiative it can be said that it has contributed to the implementation of infarction networks nationwide. In 2018, 21 261 pPCIs were performed (13 395 back in 2008) with an average rate of 416 pPCIs per million inhabitants. This rate is considered adequate given the prevalence of ischemic heart disease in our country without great differences among the different autonomous communities.9 At this point, what challenges will the next decade bring? The survey of a paper recently published by Rodriguez-Leor et al.10 in REC: Interventional Cardio­logy may have some of the answer to this question. The current objectives should focus on both the patient and the healthcare provider. At this point it is not about opening new centers or programs anymore, but about designing the procedures required for each center to keep quality outcomes. The satisfaction of well-trained professionals built on adequate retributions, regulating the rest periods, and the correct sizing of staff based on the healthcare needs are all key issues to take into consideration at the infarction centers. Similarly, generational replacement should occur while keeping the quality of the entire process. The Administration should consider payment to centers based on results and make sure that these payments reach the treating physician. On the other hand, very complex cases like STEMI patients complicated with cardiogenic shock should be referred to specialized centers capable of performing advanced ventricular assist techniques, heart surgery, and transplants. In this type of patients, mortality rate is still very high (around 50%). Therefore, each infarction network should be able to identify its shock centers for the adequate management of these patients.

Figure 1. A: induction ceremony of the scientific societies of the different autonomous communities into the Stent for Life initiative (Madrid, October 4, 2010); B: certificate of membership to the Stent for Life initiative of an affiliate society (Society of Cardiology of Castile and León).

Figure 2. Examples of news published by the media on comparative results among different autonomous communities on the management of ST-segment elevation myocardial infarction.

In conclusion, the objectives of the Stent for Life initiative in our country should look at the new clinical and professional challenges ahead with the patient as the protagonist of all clinical actions.

ACKNOWLEDGEMENTS

We wish to thank Dr. Matías Feldman, Dr. Ander Regueiro, Dr. José Ramón Rumoroso, and Dr. Miren Tellería for their dedication to the Stent for Life initiative in Spain over the last 10 years. We also wish to thank the members of the different boards of directors of the Hemodynamics and Interventional Cardiology Section of the SEC for their contribution to this paper.

CONFLICTS OF INTEREST

M. Sabaté was the national coordinator of the Stent for Life initiative in Spain between 2009 and 2013. No other conflicts of interest have been reported.

REFERENCES

Undertaking the project REC: Interventional Cardiology, a bilingual journal published in English and Spanish and devoted to interventional cardiology seems a gigantic task to implement, which is why we wish to thank the editors for their entrepreneurial spirit and also Revista Española de Cardiología for making space for this new project. A unique opportunity for developing agreements and team work for the entire Spanish-speaking cardiological community that often feels the imposing presence of English-speaking scientific journals.

Combining the organizational and academic trajectory and leadership of the Spanish Society of Cardiology and the vitality, thrust, and enthusiasm of the Latin American interventional cardiology community may be the beginning of a huge agreement of productivity and novelty. This may, in turn, help the communication network between the Spanish vision planted at the very heart of Europe and the Latin American one that influences over 600 million people, thereby exponentially increasing the opportunities of communication for members of scientific societies and the possibilities of providing relevant scientific information. Talent is universal, opportunities are not.

Although European and American clinical practice guidelines on evidence-based medicine have tremendous exposure and each country publishes its own guidelines, we have been unable to integrate these concepts in regional or intersociety guidelines or approved documents. Yet at the Latin American Society of Interventional Cardiology (Sociedad Latinoamericana de Cardiología Intervencionista, SOLACI) we have tried to integrate the interventional guidelines established by the Society for Cardiovascular Angiography and Interventions and the American College of Cardiology. REC: Interventional Cardiology could well serve as a forum for all interventional cardiology guidelines and consensus documents of our region.

We should also mention that several clinical trials, series, and clinical cases studied in Latin America, especially those including international collaborations or inter-society agreements, should be published in this journal.

Although most multicentric randomized evidence-based clinical trials that are conducted in the United States and Europe are published in English, many significant advances made in cardiovascular medicine such as saphenous vein grafts used in coronary artery bypass graft surgery, stents, and stent-grafts have come from doctors within our region, such as R.G. Favaloro, J. Palmaz, and J.C. Parodi. However, even though these advances may speak Spanish, they have been implemented by English-speaking countries, which is the main reason why cooperation and integration should be our guiding spirit. The goal of this journal is to contribute, not to compete.

Needless to say that the success of this project depends entirely on us; all interventional cardiologists in Ibero-America should convince ourselves that we are capable of producing quality educational material that is attractive, not only to us, but also to our colleagues in other specialties, both in Latin America and the rest of the world. We are convinced that this will be so.

80% of the teachers predict that by 2026 digital content will replace print. In this sense, the educational resources that turn learning into a videogame, such as virtual reality or gaming, and that are patrimony of the digital world1, will make learning a more interactive experience. The digital format of REC: Interventional Cardiology, with its tremendously dynamic character and adaptability to the user, will help amplify its educational purpose, making it an addictive yet healthy experience.

In the battle to conquer everyone’s attention, sensationalist tabloid-style material seems to have replaced academic writing. The focus should be on getting the attention of the specialists through an updated informative model that never loses its primary educational purpose.

Sitting talent and different visions at the same table multiplies the options of creativity. REC: Interventional Cardiology is a golden opportunity for generating knowledge, healthy controversy, and pushing the Latin American interventional medical practice to the limit, under the mentoring of Revista Española de Cardiología in an effort to make a useful and enriching difference in the final result published.

This will be a privileged stage for exchange and academic contribution for the Ibero-American interventional cardiology communities. Congratulations and best wishes!

CONFLICTS OF INTEREST

The authors declared no conflicts of interest whatsoever regarding this manuscript.

REFERENCES

To this day, heart transplant is the treatment of choice in patients with heart disease and functional repercussions that is refractory to treatment (both drugs and electrical or mechanical devices) and has no contraindications. The milestone that made heart transplant take the spotlight in the management of these patients was the introduction of calcineurin inhibitors as basic immunosuppressants, which allowed the effective control of acute graft rejection. Immunosuppression patterns based on cyclosporine at the beginning and then on tacrolimus have led to really long survivals with means of up to 12 years.1 After acute rejection was no longer the main cause of graft failure and occasionally the patient, the long-term survival of the graft is basically limited by the development of coronary vascular disease.

Graft vascular disease represents an accelerated phase of the underlying fibroproliferative process that affects the entire coronary vascular bed diffusely. On the pathological analysis, its appearance is different from classic atherosclerosis of complex and multifactor etiology in that it includes non-immunity factors and, in particular, immunity factors.2 As a matter of fact, it is the most conspicuous manifestation of antibody-mediated late rejection, which is why it has sometimes been referred to as “chronic graft rejection”. Its incidence based on the angiographic data we have is over 30%-50% from the third to the fifth year after the transplant which has a significant impact on prognosis: it is the leading cause of graft failure and one of the leading causes of death in recipients with long survival rates.3 Also, the management of this process is relatively limited because of its diffuse nature that makes coronary revascularization procedures more difficult.

In the study conducted by Solano-López Morel et al.4 and recently published on REC: Interventional Cardiology, authors from 2 experienced groups revealed their results with percutaneous revascularization with drug-eluting stents in one of the most severe forms of graft vascular disease: chronic total coronary occlusion. The authors confirmed that the technique was feasible since it used state-of-the-art diagnostic and therapeutic technological means, although they restricted it to highly selected patients. The findings show that chronic total coronary occlusion has a low but still significant prevalence (12.2% of the patients), late onset (mean, 10 years after the transplant), and even in experienced hands it is barely eligible for percutaneous revascularization (13.5% of the patients with chronic total coronary occlusions). Although the angiographic results are promising (93% of initial success and 2% restenosis only), the prognosis of these patients is still poor (a 21.4% cardiovascular mortality rate with a mean at follow-up of 2.8 years) even compared to graft vascular disease without complete occlusion treated percutaneously (21.4% vs 8.3%). Although the study sample is limited, it would have been interesting to draw a comparison between patients with chronic total coronary occlusions treated percutaneous or medically.

The most important thing of the study conducted by Solano-López Morel et al.4 is that it is the first time that the feasibility of the recanalization of chronic total coronary occlusions in graft vascular disease is ever reported. The results are indicative that in these patients, percutaneous procedures are nothing more than palliative care sensu stricto whose effectiveness in clinical terms has not been confirmed yet (and probably never will). This comes as no surprise since graft vascular disease is a diffuse and progressive disease that affects both the epicardial coronary arteries and the intramyocardial trajectories and especially the capillary bed. Therefore, same as it happens with other conditions, the most effective management is preventive treatment targeted at well-known etiopathogenic factors including taking good care of the donor, preventing graft primary failure, preventing and treating cytomegalovirus-related infections, the universal use of statins (such as hypolipemiant and immunomodulating statins), and preventing antibody-mediated acute and chronic cell rejection through the use of individual immunosuppression therapies for each patient.5

CONFLICTS OF INTEREST

None declared.

REFERENCES