Era Of Percutaneous Coronary Intervention Research Articles

Impact of socioeconomic status on survival following ST-elevation myocardial infarction in a universal healthcare system

BackgroundLower socioeconomic status (SES) has been associated with worse outcomes after acute myocardial infarction. Data for survival after ST-elevation myocardial infarction (STEMI) by SES in the current era of primary percutaneous coronary intervention (PCI) is more limited. MethodsData was collected for all patients with acute STEMI undergoing primary PCI at The South Yorkshire Cardiothoracic Centre, UK between 2009 and 2014. A Cox regression analysis was used to assess differences in survival by SES quartile (using an area-level measure). ResultsOf the 3126 STEMI patients, 2655 (84.9%) were first presentations of STEMI. Lower SES groups generally had a less favourable baseline cardiovascular risk factor profile, with higher rates of smoking (p = 0.001), diabetes (p = 0.007) and previous coronary heart disease (p = 0.025). With the exception of beta-blockers, the use of secondary preventative medications was similar between SES quartiles. Adjusting for age and gender, the most disadvantaged SES quartile trended to a non-significant increased mortality at 30 days (hazard ratio 1.35 (0.79–2.33)), 1 year (1.12 (0.76–1.65)), or 3 years (1.22 (0.88–1.70)) compared to the least disadvantaged SES quartile, but this was attenuated by adjusting for additional cardiovascular risk factors and medication use on discharge. ConclusionsIn this large study of unselected STEMI patients managed by primary PCI, we did not find any significant differences in survival by SES at 30 days, 1 year, or 3 years.

Abstract 337: Prognostic Impact of Cardiac Arrest Among Patients With ST-Elevation Myocardial Infarction

Background: ST-elevation myocardial infarction (STEMI) is a potentially fatal condition that may be complicated by cardiac arrest (CA). However, the impact of CA complicating STEMI on prognosis in the contemporary era of rapid primary PCI is uncertain. Methods: We reviewed consecutive cases of STEMI treated with percutaneous coronary intervention (PCI) at our center between January 1, 2011 and December 31, 2016. Baseline clinical characteristics and in-hospital long-term outcomes were compared between patients with and without CA. Results: Among 1,272 patients with STEMI, 148 (11.6%) had CA (30.4% out-of-hospital, 69.6% after ED arrival). Compared to patients without CA, patients with STEMI+CA were more likely to have a history of heart failure, valve surgery, peripheral and cerebrovascular disease, and chronic kidney disease with a trend towards increased prevalence of left main or left anterior descending culprit vessel. Patients with STEMI+CA had greater creatinine (1.28±0.92 vs. 1.07±0.67, p=0.013, infarct size (CK-MB 171.6±131.6 vs. 139.2±117.0 ng/mL, p=0.010; troponin T 6.2±6.2 vs. 5.0±4.8 ng/mL, p=0.024), door-to-balloon-time (118.1±63.6 vs. 106.8±64.0, p=0.045), and incidence of cardiogenic shock (48.0% vs. 5.9%, p<0.0001) and intra-aortic balloon pump need (36.5% vs. 8.3%, p<0.0001). Patients with STEMI+ CA had higher rates of major bleeding (25.0% vs. 9.4%, p<0.0001) and post-PCI heart failure (13.5% vs. 8.1%, p=0.042). Patients with STEMI+CA had significantly greater mortality in-hospital (14.9% vs. 3.6%, p<0.0001) and at 1-year (22.9% vs. 9.3%, p<0.0001) (Figure). Conclusions: CA is a complication in >1 in 10 patients with STEMI and is associated with significantly higher morbidity and mortality compared with STEMI without CA. Strategies to improve the care and outcomes of STEMI patients with CA are needed.

Abstract 360: Association Between Door-To-Balloon Time on Mortality in Patients With ST-Elevation Myocardial Infarction and Cardiac Arrest

Background: Door-to-balloon-time (D2BT) is a national hospital metric for quality of care among patients with ST-elevation myocardial infarction (STEMI) but STEMI patients with cardiac arrest (CA) are excluded from D2BT public reporting metrics. The association of D2BT with mortality in STEMI patients with cardiac arrest (CA) in the contemporary era of rapid primary PCI is unknown. We assessed the association of D2BT and outcomes in patients with STEMI+CA. Methods: We reviewed consecutive cases of STEMI and CA, defined as loss of pulse requiring cardiopulmonary resuscitation and/or defibrillation, treated with percutaneous coronary intervention (PCI) at our center from 1/1/11-12/31/16.We assessed characteristics and outcomes among these patients by quartile of D2BT (Q1: 21-82 minutes, Q2: 83-106 minutes, Q3: 109-139 minutes, Q4: 141-489 minutes). Results: We identified 145 patients with STEMI+CA. Increasing quartiles of D2BT were associated with higher proportion of female sex (p=0.040), Caucasian race (p=0.001), and dyslipidemia (p=0.008). The use of guideline-directed medical therapy prior to PCI (aspirin, P2Y12 inhibitor, and anticoagulant) and the occurrence of in-hospital post-PCI adverse events were similar between groups. We observed a trend toward increased in-hospital mortality associated with increasing D2BT (Q1: 8.3%, Q2: 10.8%, Q3: 19.4%, Q4: 22.2%, p=0.059, Figure). Conclusion: D2BT is associated with in-hospital mortality among patients with STEMI+CA. Efforts should be made to implement systems of care to reduce disparities in D2BT among appropriate patients within this population.

TCT-273 Italian Multicenter Registry of Bare Metal Stent Use in Modern Percutaneous Coronary Intervention Era: a multicenter observational study.

New-generation drug-eluting stents (DES) represent the first choice when performing percutaneous coronary intervention (PCI). However, there are still several clinical scenarios in which interventionists may prefer bare-metal stents (BMS) implantation, mainly because of the need of a very-short dual

Serum zinc concentration in patients with acute myocardial infarction in percutaneous coronary intervention era.

IntroductionThere were few studies that investigated the association between serum zinc concentration and acute myocardial infarction (AMI) in percutaneous coronary intervention era.ObjectiveWe assessed the relationships between serum zinc concentration, complications, and prognosis in AMI patients after primary percutaneous coronary intervention.MethodsWe conducted a single-center, prospective, observational study including 50 patients with AMI. We divided patients into two groups (High-zinc group and Low-zinc group) by median serum zinc concentration and compared two groups about clinical outcomes up to 1 year follow up.ResultsThe mean age of patients was 66.2 ± 11.8 years old. Patients in the Low-zinc group had ST-segment elevation more frequently than those in the High-zinc group (96.0% vs. 72.0%, P = 0.02). All-cause mortality at 1 year was similar in both groups (P (log-rank) = 0.33). However, the lengths of hospital stay and in coronary care unit were longer in patients in the Low-zinc group than in those in the High-zinc group (15.6 ± 9.2 days vs. 11.9 ± 2.9 days, P = 0.06; 3.9 ± 2.8 days vs. 2.3 ± 0.8 days, P = 0.01). Multivariate regression analysis showed that low serum zinc concentration was associated with the use of cardiac or respiratory assist devices (adjusted odds ratio, 17.79; 95% CI 1.123 to 1216.5; P = 0.04).ConclusionsAlthough there was no significance difference in mortality in Low-zinc and High-zinc groups, low serum zinc concentration was associated with longer stay in the coronary care unit, and was one of the independent predictors for the use of cardiac or respiratory assist devices.

P2739Right ventricular infarction: incidence, hemodynamics and clinical impact in the era of primary percutaneous coronary intervention

P2739Right ventricular infarction: incidence, hemodynamics and clinical impact in the era of primary percutaneous coronary intervention

Obesity paradox in the era of percutaneous coronary intervention with 2nd-generation drug-eluting stents: an analysis of a multicenter PCI registry.

Being overweight has been identified as independent risk factors for coronary artery disease. However, overweight patients have been reported frequently to have better mortality outcomes, and there is little data showing they are at a disadvantage regarding secondary prevention of cardiovascular events. We analyzed the influence of being overweight (defined as body mass index > 25kg/m2) on adverse events in patients who underwent everolimus-eluting stent (EES) implantation using a multicenter registry with a maximum follow-up of 3years. Propensity score matching was done for adjusting baseline characteristics. We defined primary end points as major adverse cardiac and cerebrovascular events (MACCE: a composite of mortality from all causes, nonfatal myocardial infarction, and nonfatal stroke) and "MACCE excluding non-cardiac mortality". Other adverse events were analyzed as key secondary end points. Out of 1918 patients, 450 pairs were obtained through propensity score matching. Overweight patients were superior to non-overweight patients regarding MACCE (event rates: 8.2 vs. 13.8% in overweight vs. non-overweight, respectively; log-rank p = 0.009) and "MACCE excluding non-cardiac mortality" (5.9 vs. 10.1%, p = 0.03). On secondary end points, not only did overweight patients have significantly fewer major bleeding events (2.2 vs. 4.8%, p = 0.02), but they also had smaller adverse event rates for almost all such events; the differences were not statistically significant. Overweight patients had better outcomes for MACCE, even on excluding non-cardiac mortalities. No result was supportive of an evident advantage to non-overweight EES-implanted patients in terms of secondary prevention of cardiovascular events.

Frequency of Complete Atrioventricular Block Complicating ST-Elevation Myocardial Infarction in Patients Undergoing Primary Percutaneous Coronary Intervention

Objectives: ST-segment elevation myocardial infarction (STEMI) can be associated with many conduction disturbances including complete atrioventricular block (CAVB). CAVB complicating STEMI resulted in an increased mortality before the modern era of primary percutaneous coronary intervention (PCI). The aim of this study was to ascertain the rate and risk factors for CAVB in STEMI patients undergoing rapid reperfusion with PCI. Methods: We analyzed 223 patients presenting with STEMI. Patient characteristics, procedural characteristics, and in-hospital data were compared between patients with and without CAVB. Results: Out of 223 patients, 174 underwent PCI; the majority (87%) was African-American. CAVB was present in 8 patients (4.6%), and 6 of them had RCA occlusion. Independent predictors of CAVB included diabetes mellitus, female gender, lower systolic and diastolic blood pressure, and inferior-lateral/lateral STEMI. Ten patients (5.7%) required temporary pacing at presentation; only 1 patient required permanent pacing before discharge. No patient with anterior STEMI developed CAVB. Conclusions: The incidence and in-hospital mortality rate of CAVB in patients with STEMI who underwent primary PCI was reduced when compared to data from the thrombolytic era. This may be due to faster flow recovery in the infarct-related artery achieved with PCI.

Modern Antiplatelet Therapy: When Is Clopidogrel the Right Choice?

Platelet inhibition with aspirin is the cornerstone of medical therapy for coronary artery disease. In the era of percutaneous coronary intervention with drug-eluting stents, dual anti-platelet therapy with the addition of clopidogrel (Plavix©, Bristol-Myers Squibb, New York, NY) became the mainstay of therapy. However, with the advent of newer oral antiplatelet medications, including prasugrel (Effient©, Eli Lilly, Indianapolis, Indiana) and ticagrelor (Brilinta©, Astra-Zeneca, Cambridge, United Kingdom), choosing the appropriate platelet inhibitor has become more nuanced. The optimal regimen differs based on patient characteristics, clinical situation, and the condition being treated, with differing risk and safety profiles for these medications. This review explores the appropriate use of antiplatelet therapy for stable ischemic heart disease, acute coronary syndrome, stroke, and peripheral vascular disease. Furthermore, we evaluate the data behind the use of antiplatelet therapy in patients on oral anticoagulation. By understanding the biochemistry of platelet aggregation, the pharmacology of platelet inhibitors, and the extensive clinical trial data that informs current guideline recommendations we aim to better understand the role of clopidogrel in patients with cardiovascular disease.

Beta-blocker therapy reduces mortality in patients with coronary artery disease treated with percutaneous revascularization: a meta-analysis of adjusted results.

The long-term impact of beta blockers on prognosis in patients treated with contemporary therapies for coronary artery disease remains to be defined. All observational studies evaluating the impact of beta blockers in patients treated with coronary revascularization and contemporary therapies and adjusted with multivariate analysis were included. All-cause death was the primary endpoint, while Major Adverse Cardiac Events (MACE) (composite endpoint of all-cause death or myocardial infarction, MI) and MI were secondary endpoints. A total of 26 studies were included, with 863 335 patients. After 3 (1-4.3) years, long-term risk of all-cause death was lower in patients on beta blockers [odds ratio, OR 0.69 (0.66-0.72)], both for Acute Coronary Syndrome (ACS) [OR 0.60 (0.56-0.65)], and stable angina patients [OR 0.84 (0.78-0.91)], independently from ejection fraction [OR 0.64 (0.42-0.98) for reduced ejection fraction and OR 0.79 (0.69-0.91) for preserved ejection fraction]. The risk of long-term MACE was lower but NS for ACS patients treated with beta blockers [OR 0.83 (0.69-1.00)], as in stable angina. Similarly, risk of MI did not differ between patients treated with beta blockers or without beta blockers [OR 0.99 (0.89-1.09), all 95% confidence intervals]. Using meta-regression analysis, the benefit of beta blockers was increased for those with longer follow-up. The number needed to treat was 52 to avoid one event of all-cause death for ACS patients and 111 for stable patients. Even in percutaneous coronary intervention era, beta blockers reduce mortality in patients with coronary artery disease, confirming their protective effect, which was consistent for both ACS and stable patients indifferently of preserved or reduced ejection fraction.

Successful emergent repair of a subacute left ventricular free wall rupture after acute inferoposterolateral myocardial infarction

BackgroundMyocardial rupture is an important and catastrophic complication of acute myocardial infarction. A dramatic form of this complication is a left ventricular free wall rupture (LVFWR).Case presentationA 70-year-old man with acute inferoposterolateral myocardial infarction and single-vessel coronary artery disease underwent emergency percutaneous coronary intervention (PCI). The circumflex coronary artery was successfully stented with a drug-eluting stent. Fifty days after PCI the patient experienced progressive fatigue and chest pain with haemodynamic instability. Transthoracic echocardiography showed a covered LVFWR of the lateral wall. The patient underwent successful emergent surgical repair of the LVFWR.ConclusionsIn the current era of swift PCI, mechanical complications of acute myocardial infarction, such as LVFWR, are rare. The consequences, however, are haemodynamic deterioration and imminent death. This rare diagnosis should always be considered when new cardiovascular symptoms or haemodynamic instability develop after myocardial infarction, even beyond one month after the initial event. Timely diagnosis and emergency surgery are required for successful treatment of this devastating complication.

Current knowledge on very late stent thrombosis

AbstractVery late stent thrombosis (VLST) represents a rare, but potentially lethal complication, in the era of percutaneous coronary intervention. Its etiology, pathogenesis, and predictive factors have not yet been established due to its relatively low prevalence and multifactorial nature. In this review article, after presenting the current definitions on stent thrombosis, we focus on the contemporary data on VLST, for both bare‐metal stents and drug‐eluting stents. Possible pathophysiological mechanisms and predictive factors are also illustrated, with data drawn from several multicenter studies. Factors such as younger patients, smokers at the time of initial DES implantation, STEMI or the presence of thrombus at the time of initial DES implantation, overlapping stents, seem to represent independent predictors of VLST. Finally, there is a special reference on cases of VLST, studied with optical coherence tomography (OCT). OCT managed to identify the cause of VLST in over 97% of the cases in these studies, whereas some of the most common mechanisms of VLST in these patients were stent malapposition, neoatherosclerosis rupture, uncovered struts, and stent underexpansion.

Coronary Stents: History, Design, and Construction.

The history of percutaneous coronary intervention (PCI) is marked by rapid technological advancements that have taken place over the past 40 years. After a period of balloon angioplasty, which was marred by risk of abrupt vessel closure and vessel recoil, balloon expandable metal alloy stents were the mainstay of PCI. The introduction of drug eluting stents (DES) targeted in-stent restenosis, a common mode of stent failure, and ushered in the current PCI era. Since the first generation of DES, advances in polymer science and stent design have advanced the field. The current generation of DES has thin struts, are highly deliverable, have biocompatible or absorbable polymers, and outstanding safety and efficacy profiles. In this review, we discuss the technological advancements in stent development, design, and construction, with an emphasis on balloon expandable stents. The aspects of stent properties, metal alloys, bioresorbable vascular scaffolds, drug elution, and polymers will be covered.

Prevalence and Predictive Value of Microvascular Flow Abnormalities after Successful Contemporary Percutaneous Coronary Intervention in Acute ST-Segment Elevation Myocardial Infarction

Although microvascular flow abnormalities have been observed following epicardial recanalization in acute ST-segment elevation myocardial infarction (STEMI), the prevalence and severity of these abnormalities in the current era of rapid percutaneous coronary intervention (PCI) has not been evaluated. The objective of this study was to assess microvascular perfusion (MVP) following successful primary PCI in patients with STEMI and how it affects clinical outcome. In this single-center, retrospective study, 170 patients who successfully underwent emergent PCI for STEMI were assessed using real-time myocardial contrast echocardiography using a continuous infusion of intravenous commercial microbubbles (3% Definity). Three patterns of myocardial contrast replenishment were observed following intermittent high-mechanical index impulses: infarct zone replenishment within 4sec (normal MVP), delays in contrast replenishment but normal plateau intensity (delayed MVP [dMVP]), and both delays in replenishment and reduced plateau intensity (microvascular obstruction [MVO]). Changes in left ventricular ejection fraction at 6months and clinical event rate at 12months (death, recurrent infarction, need for defibrillator placement, or heart failure admission) were compared. Normal MVP was seen in 62 patients (36%), dMVP in 49 (29%), and MVO in 59 (35%). Left anterior descending coronary artery infarct location was the only parameter independently associated with dMVP or MVO, independent of age, cardiac risk factors, door-to-dilation time, pre-PCI Thrombolysis In Myocardial Infarction flow grade, and thrombus burden. A dMVP pattern had a similar reduction in left ventricular ejection fraction as MVO at hospital discharge but had recovery of left ventricular ejection fraction at 6months and a greater than fourfold lower event rate than the MVO group (P<.001). MVO and dMVP are frequently seen following contemporary successful PCI for STEMI, especially following left anterior descending coronary artery infarction. Despite a similar area at risk, a dMVP pattern has better functional recovery and clinical outcome than MVO.

Effects of Bisoprolol Are Comparable with Carvedilol in Secondary Prevention of Acute Myocardial Infarction in Patients Undergoing Percutaneous Coronary Intervention.

Although the benefits of carvedilol have been demonstrated in the era of percutaneous coronary intervention (PCI), very few studies have evaluated the efficacy of bisoprolol in the secondary prevention of acute myocardial infarction (MI) in patients treated with PCI. We hypothesized that the effect of bisoprolol would not be different from carvedilol in post-MI patients. A total of 13,813 patients who underwent PCI were treated either with carvedilol or bisoprolol at the time of discharge. They were enrolled from the Korean Acute MI Registry (KAMIR). After 1:2 propensity score matching, 1,806 patients were enrolled in the bisoprolol group and 3,612 patients in the carvedilol group. The primary end point was the composite of major adverse cardiac events (MACEs), which was defined as cardiac death, nonfatal MI, target vessel revascularization, and coronary artery bypass surgery. The secondary end point was defined as all-cause mortality, cardiac death, nonfatal MI, any revascularization, or target vessel revascularization. After adjustment for differences in baseline characteristics by propensity score matching, the MACE-free survival rate was not different between the groups (HR=0.815, 95% CI:0.614–1.081, p=0.156). In the subgroup analysis, the cumulative incidence of MACEs was lower in the bisoprolol group in patients having a Killip class of III or IV than in the carvedilol group (HR=0.512, 95% CI: 0.263–0.998, p=0.049). The incidence of secondary end points was similar between the two beta-blocker groups. In conclusion, the benefits of bisoprolol were comparable with those of carvedilol in the secondary prevention of acute MI.

Left Ventricular Free Wall Rupture Following Acute Myocardial Infarction: A South Canterbury Experience

Left ventricular free wall rupture following acute myocardial infarction is a rare but significant complication in the current era of percutaneous coronary intervention. Unfortunately, the risk remains high in secondary hospitals where thrombolysis continues to be the primary management for all patients presenting with acute ST elevation myocardial infarction (STEMI). We present the case of a 69 year old lady who presented with a late presentation posterolateral STEMI who was thrombolysed and subsequently developed an early subacute rupture. This was confirmed on transthoracic echocardiography. On review of the literature, we note the potential dangers of routinely thrombolysing all apparent STEMIs who present to secondary hospitals. Careful clinical consideration should be undertaken before we potentially add to the patient's list of complications. This would be an important consideration given the current South Canterbury patient demographics and generally stoic population whose access to health care have geographical limitations.

Cardiac Rupture Complicating Acute Myocardial Infarction in the Percutaneous Coronary Intervention Era: Clinical Features

Cardiac Rupture Complicating Acute Myocardial Infarction in the Percutaneous Coronary Intervention Era: Clinical Features

Utility of the ACC/AHA lesion classification as a predictor of procedural, 30-day and 12-month outcomes in the contemporary percutaneous coronary intervention era.

Correlations between the ACC/AHA coronary lesion classification and clinical outcomes in the contemporary percutaneous coronary intervention (PCI) era are not well established. We analyzed clinical characteristics and outcomes according to ACC/AHA lesion classification (A, B1, B2, C) in 13,701 consecutive patients from the Melbourne Interventional Group (MIG) registry. Patients presenting with STEMI, cardiogenic shock and out-of-hospital cardiac arrest were excluded. The primary endpoints were 30-day and 12-month mortality. Secondary endpoints were procedural success as well as 30-day and 12-month major adverse cardiac events. Of the 13,701 patients treated, 1,246 (9.1%) had type A lesions, 5,519 (40.3%) had type B1 lesions, 4,449 (32.5%) had Type B2 lesions and 2,487 (18.2%) had Type C lesions. Patients with type C lesions were more likely to be older and have impaired renal function, diabetes, previous myocardial infarction, peripheral vascular disease and prior bypass graft surgery (all P < 0.01). They were also more likely to require rotational atherectomy, drug-eluting stents and longer stent lengths (all P < 0.01). Increasing lesion complexity was associated with lower procedural success (99.6% vs. 99.1% vs. 96.6% vs. 82.7%, P < 0.001) and worse 30-day (0.2% vs. 0.3% vs. 0.7% vs. 0.6%, P < 0.001) and 12-month mortality (2.2% vs. 2.0% vs. 3.2% vs. 2.9%, P <0.01). Kaplan Meier analysis showed complex lesions (type B2 and C) had lower survival at 12-months (P = 0.003). PCI to more complex lesions continues to be associated with lower procedural success rates as well as inferior medium-term clinical outcomes. Thus the ACC/AHA lesion classification should still be calculated preprocedure to predict acute PCI success and clinical outcomes.

The prognostic significance of smoking cessation after acute coronary syndromes: an observational, multicentre study from the Melbourne interventional group registry

ObjectiveWe aim to ascertain the prognostic significance of persistent smoking and smoking cessation after an acute coronary syndrome (ACS) in the era of percutaneous coronary intervention (PCI) and optimal secondary...

TCT-133 Clinical Impact of Persistent Microvascular Obstruction Following Successful Percutaneous Coronary Intervention in Acute ST segment Elevation Myocardial Infarction

In the contemporary era of primary percutaneous coronary intervention (PPCI) to treat acute ST segment elevation myocardial infarction (STEMI), the frequency and predictors of persistent microvascular obstruction (MVO) have not been elucidated. Real time myocardial contrast echocardiography (RTMCE)