Course Of Percutaneous Coronary Intervention Research Articles

Anticoagulation profile of staged-dose vs. single-dose enoxaparin for trans-radial percutaneous coronary intervention

Abstract Background Anticoagulation is indicated in patients undergoing trans-radial coronary angiography (CAG) with or without percutaneous coronary intervention (PCI). However, full-dose enoxaparin given before CAG to all patients may cause over-anticoagulation in those without indication for subsequent PCI. Purpose This study prospectively assessed the anticoagulation profile of staged-dose (0.5±0.25 mg/kg) vs. single-dose (0.75 mg/kg) enoxaparin in troponin-negative patients undergoing elective trans-radial PCI. Methods Eligible patients were randomly assigned to the Planned Staged-dose group or the Planned Single-dose group. In the Planned Staged-dose group, enoxaparin 0.5 mg/kg was administered to all patients before CAG and additional 0.25 mg/kg was given only to those undergoing subsequent PCI immediately before PCI. In the Planned Single-dose group, all patients received enoxaparin 0.75 mg/kg before CAG irrespective of their indication for subsequent PCI. Patients undergoing subsequent PCI in each group were defined as Staged-dose and Single-dose groups, respectively. Anti-Xa levels were assessed at 0 min (before) and 10 min after enoxaparin administration (CAG-0min and CAG-10min, respectively), and 0 min (before) and 10 min after the beginning of PCI (PCI-0min and PCI-10min, respectively), and at the end of PCI (PCI-end). Therapeutic anticoagulation was defined as anti-Xa levels of 0.5–1.2 IU/ml before PCI and 0.5–1.8 IU/ml during PCI, respectively. Bleeding was according to the thrombolysis in myocardial infarction (TIMI) criteria. Results In 170 randomized patients, 38 of 85 and 37 of 85 patients were included in the Staged-dose and the Single-dose groups, respectively. The baseline characteristics were well balanced between the two groups. The anti-Xa levels were lower before PCI (CAG-10min: 0.903±0.124 IU/ml vs. 1.303±0.207 IU/ml, p<0.001; PCI-0min: 0.874±0.149 IU/ml vs. 1.215±0.185 IU/ml, p<0.001) and higher during PCI (PCI-10min: 1.207±0.190 IU/ml vs. 1.083±0.157 IU/ml, p=0.004; PCI-end: 1.079±0.237 IU/ml vs. 1.050±0.255 IU/ml, p=0.62) in patients receiving staged-dose vs. single-dose enoxaparin (Figure 1). The percentages of patients with therapeutic anticoagulation were higher before PCI (CAG-10min: 100% [35/35] vs. 30.6% [11/36], p<0.001; PCI-0min: 96.8% [30/31] vs. 54.1% [20/37], p<0.001) and similar during PCI (PCI-10min: 100% [34/34] vs. 100% [36/36], p=1.000; PCI-end: 97.2% [35/36] vs. 100% [36/36], p=1.000) in the Staged-dose vs. the Single-dose group. No TIMI major or minor bleeding occurred within 24 h of randomization in both groups. Conclusions Although both regimens of enoxaparin achieved adequate anticoagulation during the entire course of PCI, the staged-dose compared to the single-dose regimen reduced over-anticoagulation before PCI. The staged-dose enoxaparin would be a superior anticoagulation regimen in patients undergoing trans-radial CAG, especially when the indication for subsequent PCI is unclear. Figure 1. Staged-dose vs. Single-dose Funding Acknowledgement Type of funding source: Public hospital(s). Main funding source(s): 2016 Peking Union Medical College Hospital (PUMCH) Science Fund for Junior Faculty

Left internal mammary spasm mimicking graft dissection in the course of percutaneous coronary intervention of anastomotic in-stent restenosis

Left internal mammary spasm mimicking graft dissection in the course of percutaneous coronary intervention of anastomotic in-stent restenosis

Safety and Effectiveness of Bivalirudin in Patients Undergoing Percutaneous Coronary Intervention: A Systematic Review and Meta-Analysis.

Recent clinical trials have shown that while bivalirudin exhibits similar efficacy with heparin, it offers several advantages over heparin, such as a better safety profile. We aimed to evaluate the efficacy and safety of bivalirudin use during Percutaneous Coronary Intervention (PCI) in the treatment of angina and acute coronary syndrome (ACS). We searched the Cochrane Central Register of Controlled Trials (CENTRAL) in the Cochrane Library, PubMed, EMBASE, and Science Direct from January 1980 to January 2016. Randomized controlled trials (RCTs) comparing bivalirudin to heparin during the course of PCI in patients with angina or ACS were included. Outcome measures included all-cause mortality, myocardial infarction, revascularisation, stent thrombosis, stroke, and major bleeding. The selection, quality assessment, and data extraction of the included trials were done independently by four authors, and disagreements were resolved by consensus. Pooled relative risk (RR) estimates and 95% confidence intervals (CIs) were calculated. A total of 12 RCTs involving 44,088 subjects were included. Bivalirudin appeared to be non-superior compared to heparin in reducing all-cause mortality, myocardial infarction, revascularisation, and stroke. Bivalirudin appeared to be related to a higher risk of stent thrombosis when compared to heparin plus provisional use of a glycoprotein IIb/IIIa inhibitor (GPI) at day 30 (RR 1.94 [1.16, 3.24] p < 0.01). Overall, bivalirudin-based regimens present a lesser risk of major bleeding (RR 0.56 [0.44–0.71] p < 0.001), and Thrombolysis In Myocardial Infarction (TIMI) major bleeding (RR 0.56 [0.43–0.73]) compared with heparin-based regimens either with provisional or routine use of a GPI. However, the magnitude of TIMI major bleeding effect varied greatly (p < 0.001), depending on whether a GPI was provisionally used (RR 0.42 [0.34–0.52] p < 0.001) or routinely used (RR 0.60 [0.43 –0.83] p < 0.001), in the heparin arm. This meta-analysis demonstrated that bivalirudin is associated with a lower risk of major bleeding, but a higher risk of stent thrombosis compared to heparin.

Changes in Intra-QRS Frequency Distribution Induced by Exercise Stress Test and Percutaneous Coronary Intervention in Patients with Coronary Heart Disease

Purposes: The aim of this study was to investigate the intra-QRS frequency distribution induced by transient myocardial ischemia. Methods: Sixty patients undergoing the exercise stresses Tl201scintigraphy (Tl201scinti.) and ten patients undergoing percutaneous coronary intervention (PCI) were subjects in this study. ECGs were recorded before and after Tl201scinti. or PCI. The wavelet transform using Gabor function was applied to time-frequency analysis of ECGs. The frequency power during QRS was integrated every 80 scale bands, ranged from 1 to 150 Hz, (ITFP; integrated time frequency powers) by which an intra-QRS frequency distribution was represented. Results: The ITFP was changed in 47.5% cases with positive Tl201scinti. In 11 cases, the ITFP was significantly increased in the average frequency range from 72.2 to 90.3 Hz, and significantly decreased from 20.5 to 39.0 Hz in 8 cases after Tl201scinti. The similar changes in the ITFP induced by transient myocardial ischemia were observed during the time course of PCI. Conclusions: These results suggested that exercise-induced ischemia affects the distribution of frequency power within QRS complex. This analysis may offer a new information about invisible QRS changes by exercise-induced ischemia.

Protecting the Myocardial Cell During Coronary Revascularization

Using the ischemic myocardial cell as a paradigm, competitive coronary revascularization technologies will be analyzed for their potential in causing additional myocardial cell damage during the course of therapeutic procedures. Percutaneous coronary intervention (PCI) using balloon and/or stent (bare metal or coated) approaches may be associated with myonecrosis related to atherosclerotic debris plugging the downstream coronary microcirculation as well as ischemia/reperfusion injury associated with revascularization of occluded coronary vessels. The placement of distal mechanical devices and filters during the course of PCI has not been successful in ameliorating this problem. Coronary revascularization using coronary artery bypass grafting (CABG) similarly may be associated with myocardial stunning and cell necrosis associated with ischemia/reperfusion injury. Surgically induced myocardial ischemia secondary to aortic cross clamping, results from the attenuation or cessation of coronary blood flow such that oxygen delivery to the myocardium is insufficient to meet basal myocardial requirements to preserve cellular membrane stability and viability. Recovery involves: (1) resumption of normal oxidative metabolism and the restoration of myocardial energy reserves; (2) reversal of ischemia induced cell swelling and loss of membrane ion gradients and the adenine nucleotide pool; (3) repair of damaged cell organelles such as the mitochondria and the sarcoplasmic reticulum. Despite meticulous adherence to presently known principles of surgical myocardial protection using advanced cardioplegic technologies, some patients require inotropic support and/or mechanical assist devices postoperatively, when none was required preoperatively. Which method of coronary revascularization causes the least amount of myocardial cell injury and is associated with superior long-term outcomes remains an area of increasing controversy.