Daily Cardiology Research Analysis
A blinded international RCT (BALI) shows that adding intravascular lithotripsy before stenting in severely calcified coronary lesions reduces procedural failure/target vessel failure at 1 year. Post-hoc analyses of DPPOS and DaQing cohorts demonstrate that achieving prediabetes remission halves long-term risk of cardiovascular death or heart failure hospitalization. A pre-registered meta-analysis supports cardiovascular MRI as an accurate first-line test for suspected NSTE-ACS with strong progno
Summary
A blinded international RCT (BALI) shows that adding intravascular lithotripsy before stenting in severely calcified coronary lesions reduces procedural failure/target vessel failure at 1 year. Post-hoc analyses of DPPOS and DaQing cohorts demonstrate that achieving prediabetes remission halves long-term risk of cardiovascular death or heart failure hospitalization. A pre-registered meta-analysis supports cardiovascular MRI as an accurate first-line test for suspected NSTE-ACS with strong prognostic value.
Research Themes
- Optimizing coronary intervention in calcified lesions
- Metabolic disease remission as a cardiovascular prevention target
- Advanced imaging for NSTE-ACS triage and prognosis
Selected Articles
1. Balloon Lithotripsy Added to Conventional Preparation Before Stent Implantation in Severely Calcified Coronary Lesions.
In an assessor-blinded international RCT of 200 patients with severely calcified coronary lesions, adding intravascular lithotripsy to conventional lesion preparation reduced the 1-year composite of procedural or target vessel failure (35% vs 52%; RR 0.69, p=0.02). The benefit was primarily driven by less residual area stenosis ≥20% by OCT, with no safety penalty.
Impact: This is the first randomized evidence supporting routine intravascular lithotripsy to optimize stent implantation in severely calcified lesions, addressing a major unmet need in PCI.
Clinical Implications: For severely calcified lesions, consider adding intravascular lithotripsy to lesion preparation to improve stent expansion and reduce procedural failure; this may inform guideline updates and cath-lab protocols.
Key Findings
- Primary composite endpoint at 1 year was lower with lithotripsy (35%) vs conventional preparation (52%); RR 0.69 (95% CI 0.48–0.97), p=0.02.
- Residual area stenosis ≥20% by OCT occurred less frequently with lithotripsy (32% vs 45%; RR 0.73, 95% CI 0.49–1.04).
- Safety endpoints were similar between groups, indicating no safety trade-off with lithotripsy.
Methodological Strengths
- Randomized, assessor-blinded international trial design with prespecified composite endpoint
- Objective intravascular OCT assessment of stent expansion/residual stenosis
Limitations
- Modest sample size (N=200) limits power for individual hard clinical endpoints
- Effect mainly driven by imaging-based residual stenosis; generalizability to diverse devices/settings needs confirmation
Future Directions: Larger, multicenter RCTs powered for clinical events should assess whether IVL-driven optimization translates into lower MI and revascularization rates and define cost-effectiveness.
BACKGROUND: Percutaneous coronary intervention in severely calcified lesions is associated with an increased risk for procedural complications and impaired clinical outcomes. Intravascular lithotripsy is a balloon-based technique that uses pressure waves to fracture calcified plaques. However, no randomized evidence supports the routine use of lithotripsy in clinical practice. OBJECTIVES: The aim of this study was to evaluate the efficacy and safety of adding lithotripsy to conventional lesion preparation in severely calcified lesions. METHODS: In an international and assessor-blinded trial, patients with severely calcified coronary lesions were randomized to lesion preparation with vs without lithotripsy before stent implantation. The primary composite endpoint consisted of procedural failure (failed or no stent delivery, or residual area stenosis ≥20% by optical coherence tomography) or target vessel failure (cardiac death, myocardial infarction, or clinically driven revascularization) at 1 year. RESULTS: Ninety-nine patients were randomized to lithotripsy and 101 patients to conventional lesion preparation. The primary endpoint occurred in 35 patients (35%) in the lithotripsy group vs 52 patients (52%) in the conventional group (RR: 0.69; 95% CI: 0.48-0.97; P = 0.02). Residual area stenosis ≥20% was the most frequent component of the primary endpoint and occurred in 32 patients (32%) in the lithotripsy group vs 45 patients (45%) in the conventional group (RR: 0.73; 95% CI: 0.49-1.04). Safety endpoints did not differ between groups. CONCLUSIONS: Adding lithotripsy to lesion preparation using conventional techniques before stent implantation in severely calcified lesions reduced the combined incidence of procedural failure or target vessel failure at 1 year. The reduced incidence was driven primarily by a reduction in residual area stenosis ≥20%. (Balloon Lithoplasty for Preparation of Severely Calcified Coronary Lesions [BALI]; NCT04253171).
2. Prediabetes remission and cardiovascular morbidity and mortality: post-hoc analyses from the Diabetes Prevention Program Outcome study and the DaQing Diabetes Prevention Outcome study.
Across two landmark diabetes prevention cohorts with 20–30 years of follow-up, achieving prediabetes remission was associated with substantially lower risk of cardiovascular death or heart failure hospitalization (HR 0.41 in DPPOS and HR 0.49 in DaQing). Benefits persisted even when remission occurred at least once during follow-up (HR 0.43), supporting remission as a valid prevention endpoint.
Impact: By linking glycemic remission to decades-long cardiovascular benefit, this analysis reframes prediabetes management toward remission as a concrete prevention target with potential policy and guideline implications.
Clinical Implications: Lifestyle programs and pharmacotherapies should prioritize achieving normal glucose regulation in prediabetes to reduce long-term CV death/HF admissions; health systems may adopt remission as a tracked quality metric.
Key Findings
- In DPPOS (n=2402; median 20 years), prediabetes remission was associated with lower CV death/HF hospitalization (adjusted HR 0.41; 95% CI 0.20–0.84).
- In DaQing (n=540; 30 years), remission similarly reduced the primary endpoint (HR 0.49; 95% CI 0.28–0.84).
- Benefits persisted when considering remission achieved at least once during follow-up (HR 0.43; 95% CI 0.29–0.63).
Methodological Strengths
- Two independent landmark cohorts with very long-term follow-up (20–30 years)
- Rigorous adjustment (IPTW) and confirmatory pooled meta-analysis across datasets
Limitations
- Post-hoc, observational analyses within trials—remission was not randomized
- Potential residual confounding and generalizability limited to specific populations and eras of care
Future Directions: Prospective interventional studies targeting remission as a prespecified endpoint should quantify CV benefits and evaluate scalable health system strategies to achieve and maintain remission.
BACKGROUND: Prediabetes is associated with increased risk of cardiovascular disease and heart failure. Multicomponent lifestyle interventions, including diet and physical activity targeting weight loss are recommended for prediabetes management, although their long-term impact on cardiovascular outcomes remains unclear. Reaching prediabetes remission by restoring normal glucose regulation has been shown to profoundly reduce future type 2 diabetes risk outlasting the time of lifestyle intervention. We aimed to investigate whether prediabetes remission is associated with a lower incidence of cardiovascular death or hospitalisation for heart failure compared with non-remission, with a long-term legacy effect. METHODS: Post-hoc analyses were performed from two landmark diabetes prevention trials, the US Diabetes Prevention Program Outcomes Study (DPPOS) and the Chinese DaQing Diabetes Prevention Outcomes Study (DaQingDPOS). Remission was assessed using the American Diabetes Association criteria after 1 year (DPPOS) or 6 years (DaQingDPOS) of intervention. The primary endpoint was cardiovascular death or hospitalisation for heart failure over 20 and 30 years, respectively. In DPPOS, inverse probability of treatment weighting adjusted for baseline differences. A unifying meta-analysis was calculated across both data sets for the primary endpoint and all-cause mortality. FINDINGS: For DPPOS, follow-up time is reported from the start of the original Diabetes Prevention Program trial, July 31, 1996, to the end of DPPOS phase 3, Feb 23, 2020. In total, 2402 participants were included in DPPOS and 540 in DaQingDPOS. In DPPOS, 275 (11·5%) of 2402 participants reached remission after 1 year of intervention compared with 2127 (88·5%) of 2402 not reaching remission. In DPPOS, after a median follow-up of 20 years, the event rate for cardiovascular death or hospitalisation of heart failure was 1·74 (95% CI 0·87-3·48) per 1000 person-years in participants who reached remission versus 4·17 (95% CI 3·55-4·89) in those without remission (p=0·013) with a fully adjusted hazard ratio of 0·41 (95% CI 0·20-0·84; p=0·014). Results remained robust after adjustment, were confirmed in DaQingDPOS (primary endpoint: HR 0·49 [95% CI 0·28-0·84]; p=0·010), and were supported by a pooled meta-analysis. Results were stable when analysing the composite endpoint in those reaching remission at least once during follow-up, with a HR of 0·43 (0·29-0·63; p<0·0001). INTERPRETATION: Reaching prediatbetes remission is linked to a decades-long benefit, halving the risk of cardiovascular death or hospitalisation for heart failure in diverse populations. Targeting remission might represent a new approach to cardiovascular prevention. FUNDING: German Center for Diabetes Research via the German Federal Ministry of Research, Technology and Space; Ministry of Science, Research, and the Arts Baden-Württemberg; Helmholtz Munich; the Helmholtz Young Investigators Groups funding programme; the Cluster of Excellence EXC-2124; and the German Research Foundation (DFG). For DaQIng: Centers for Disease Control and Prevention, WHO, the China-Japan Friendship Hospital, and Da Qing First Hospital and Fuwai Hospital, Chinese Academy of Medical Sciences. For DPPOS: National Institute of Diabetes and Digestive and Kidney Diseases. TRANSLATIONS: For the German and Chinese translation of the abstract see Supplementary Materials section.
3. Diagnostic accuracy and prognostic value of CMR in patients with suspected acute coronary syndrome: a meta-analysis.
In 16 studies (1,386 patients), CMR showed high diagnostic accuracy for obstructive CAD (sensitivity 85%, specificity 73%) and for NSTE-ACS (sensitivity 83%, specificity 89%). Prognostically, CMR achieved excellent sensitivity (98%) and good specificity (85%) for ACS-related outcomes, with an LR− of 0.03, supporting its use as a first-line test in suspected NSTE-ACS.
Impact: This pre-registered meta-analysis consolidates the diagnostic and prognostic performance of CMR in suspected NSTE-ACS, informing triage strategies and potentially reducing unnecessary invasive angiography.
Clinical Implications: CMR can be considered early in the diagnostic pathway for suspected NSTE-ACS to identify obstructive CAD, rule-in ACS, and stratify risk, especially where troponin/ECG are equivocal.
Key Findings
- For obstructive CAD detection, pooled sensitivity 85% and specificity 73% (LR+ 3.20; LR− 0.20).
- For NSTE-ACS diagnosis, pooled sensitivity 83% and specificity 89% (LR+ 7.45; LR− 0.20).
- For prognosis (ACS-related outcomes), sensitivity 98% and specificity 85% with LR− 0.03, indicating strong negative predictive value.
Methodological Strengths
- PROSPERO pre-registration and bivariate random-effects modeling across multiple endpoints
- Separate pooled estimates for obstructive CAD, NSTE-ACS diagnosis, and prognostic outcomes
Limitations
- Heterogeneity in CMR protocols and study populations; limited number of prognostic studies (n=4)
- Potential publication bias and technology evolution over time may influence pooled estimates
Future Directions: Head-to-head pragmatic trials comparing early CMR versus invasive angiography-first strategies in suspected NSTE-ACS should evaluate clinical outcomes, resource use, and cost-effectiveness.
AIM: Cardiovascular magnetic resonance (CMR) could be considered as first diagnostic test in patients with suspected non-ST-elevation acute coronary syndrome (NSTE-ACS), since up to one-third do not have obstructive coronary artery disease (CAD). This meta-analysis aimed to investigate 1) the diagnostic accuracy of CMR to detect obstructive CAD and NSTE-ACS, and 2) the prognostic value of CMR in patients with suspected NSTE-ACS. METHODS AND RESULTS: Pubmed, Embase and Cochrane library were searched (November 30th 2024) for eligible studies. To determine the diagnostic accuracy of CMR prior to invasive coronary angiography, sensitivity, specificity, and likelihood ratios (LR+/-) were calculated for each endpoint. Data was pooled using a bivariate random-effects model. This meta-analysis was pre-registered in PROSPERO (CRD42024625306). Sixteen studies with 1.386 patients were included. The pooled sensitivity and specificity to detect obstructive CAD (eight studies) were 85% (95%CI 78-91%) and 73% (95%CI 57-85%). The pooled LR+ and LR- were 3.20 (95%CI 1.78-5.73) and 0.20 (95%CI 0.11-0.36). The pooled sensitivity and specificity to diagnose NSTE-ACS (five studies) were 83% (95%CI 73-89%) and 89% (95%CI 72-96%). The pooled LR+ and LR- were 7.45 (95%CI 2.77-20.02) and 0.20 (95%CI 0.13-0.30). Finally, the pooled sensitivity and specificity for prognosis based on ACS-related outcomes (four studies) were 98% (95%CI 42-100%) and 85% (95%CI 65-95). The pooled LR+ and LR- were 6.55 (95%CI 2.45-17.54) and 0.03 (95%CI 0-1.54). CONCLUSION: CMR can detect obstructive CAD and diagnose NSTE-ACS with excellent pooled sensitivity and specificity. CMR findings are strongly associated with clinical outcome in patients with suspected NSTE-ACS.