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.
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.
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.