Late Major Adverse Cardiovascular Events Research Articles

Abstract 15834: The Utility of Intra-Operative Coronary Doppler Profiles in Predicting Early and Late Major Adverse Cardiovascular Events After Arterial Switch Operation

Introduction: Coronary artery transfer is the most important technical point in the arterial switch operation (ASO). Intra-operative echocardiography identifies aberrancies in coronary artery Doppler profiles guiding immediate surgical management. Objective: We sought to determine whether abnormal intra-operative coronary artery Doppler profiles are associated with major adverse cardiovascular events (MACE; death, transplantation, heart failure, arrhythmia, need for coronary re-intervention) following ASO at 30-days, 5 & 10 years. Methods: Single centre retrospective review of patients undergoing ASO between 2009 - 2022. Transesophageal or epicardial intra-operative coronary artery Doppler profiles were analysed. Patient variables were abstracted from records. Freedom from MACE was estimated using Kaplan-Meier methods. Results: 347 patients were included. Coronary anatomy was usual (1LCx2R) in 237 (68%), single sinus ostia in 24 (7%), intramural in 14 (4 %). Overall 30-day MACE was 11.2% [8.3%, 15.1%], increasing to 25% [12.1, 47.4%] with single sinus ostia & 35.7% [16.7%, 65.7%] with intramural. Overall 5 & 10-year MACE was 16.5% [12.9, 20.9%], 33.8% [18.5%, 56.4%] with single sinus ostia & 50.0% [27.8%, 77.1%] with intramural. A higher probability of MACE was seen with coronary Doppler reverse flow, absence of normal pattern (Table 1) and a higher peak velocity (Figure 1). Overall 30-day mortality was 1.2% [95%CI 0.4%, 3.0%] and at 5 & 10 years was 6.5% [4.3%, 9.8%]. Conclusions: Intra-operative abnormal coronary artery Doppler profiles during ASO may identify those at highest risk of early and late adverse events, guiding follow-up surveillance strategies.

The Prognostic Value of Cardiac Biomarkers in Patients with Acute Myocardial Infarction during and after Hospitalization.

Myocardial infarction (MI) carries a strong risk of death and the development of major adverse cardiovascular events (MACE). A number of biomarkers have been proposed for risk stratification among patients with MI. The aim of this study was to determine whether elevated galectin-3 and midregional-pro atrial natriuretic peptide (MR-proANP) levels can be used as predictors of MACE in patients with acute myocardial infarction (AMI). Plasma levels of galectin-3 and MR-proANP were collected from 96 patients following their first AMI hospitalised in our clinic over the course of a year. Samples were taken on admission, and on the first and fifth day of hospitalization. During hospitalization, all patients were followed up for the occurrence of early major adverse cardiac events (MACE), defined as sudden cardiac arrest, new onset atrial fibrillation and need to use pressor amines. All patients were also followed up twelve months after AMI for the occurrence of late MACE defined as cardiac death, reinfarction and need for unscheduled PCI. Patients who experienced early MACE had significantly higher galectin-3 and MR-proANP levels assessed on admission (p = 0.007, p = 0.003). ROC curve analysis found also galectin-3 concentration assessed on admission to be a strong predictor of late MACE (AUC = 0.75, p = 0.0061). MRproANP does not appear to have any value in predicting late MACE. A high concentration of galectin-3 and MR-proANP observed on admission in patients with acute myocardial infarction has significant prognostic value: it may identify patients at high risk of early adverse cardiac events after AMI. In contrast to MR-proANP, a high concentration of galectin-3 observed on admission may also identify patients at high risk of late MACE.

Early and late recurrent cardiovascular events among high-risk patients with an acute coronary syndrome: Meta-analysis of phase III studies and implications on trial design.

BackgroundDespite low‐density lipoprotein cholesterol‐lowering therapies and other standard‐of‐care therapy, there remains a substantial residual atherosclerotic risk among patients with an acute coronary syndrome (ACS). This study aims to estimate the risk of early and late recurrent major adverse cardiovascular events (MACE) and address its implications on trial design.MethodsA literature search was performed to collect phase III interventional trials on high‐risk ACS patients. Pooled event rates at 90 and 360 days were estimated by fitting random‐effects models using the DerSimonian–Laird method. Under the assumption of a total sample size of 10,000 and 1:1 allocation at a one‐sided alpha of 0.025 using the log‐rank test, the relationship between power and relative risk reduction (RRR) or absolute risk reduction (ARR) was explored for early versus late MACE endpoint.ResultsSeven trials representing 82,727 recent ACS patients were analyzed. The pooled rates of recurrent MACE were 4.1% and 8.3% at 90 and 360 days. Approximately 49% of events occurred within the first 90 days. Based on the estimated risks at 90 and 360 days, to attain 90% statistical power, a lower magnitude of RRR is required for late MACE than early MACE (22% vs. 30%), whereas a lower magnitude of ARR is required for early MACE than late MACE (1.2% vs. 1.8%).ConclusionThe initial 90‐day window after ACS represents a vulnerable period for recurrent events. From a trial design perspective, determining a clinically important benefit by RRR versus ARR may influence the decision between early and late MACE as the study endpoint.

Early and Late Recurrent Cardiovascular Risk in Patients With Recent Acute Coronary Syndrome: Meta-Analysis and Implications in Trial Design†

Lead Author's Financial Disclosures G.C. has receieved research grant support to the Beth Israel Deaconess Medical Center, Harvard Medical School from Portola Pharmaceuticals, Bayer, Janssen Scientific Affairs, and CSL Beh-ring. Study Funding CSL Behring. Background/Synopsis Despite optimal medical therapy, a substantial residual atherosclerotic risk exists among patients with an acute coronary syndrome (ACS). Objective/Purpose This study aimed to estimate the risk of early and late major adverse cardiovascular events (MACE) and address its implications in trial design. Methods A comprehensive search was performed to collect phase III interventional trials on high-risk ACS patients. Pooled event rates at 90 and 360 days were estimated with meta-analytic approaches by fitting a random-effects model using the DerSimonian-Laird method. Using the log-rank test (n=10,000; 1-sided α=0.025)), the relationship between power and relative risk reduction (RRR) or absolute risk reduction (ARR) was explored for early vs. late MACE endpoint. Results A total of 82,727 high-risk patients with recent ACS from 7 trials were analyzed. Pooled rates of recurrent MACE were 4.1% (95% CI: 3.0% to 5.7%) at 90 days and 8.3% (95% CI: 7.1% to 9.8%) at 360 days. Approximately 49% of events occurred within the first 90 days. To attain 90% statistical power, a lower RRR is required for late MACE (22% vs. 30%), whereas a lower ARR is required for early MACE (1.2% vs. 1.8%). Conclusions The initial 90-day window after an ACS event represents a vulnerable period for recurrent MACE. From a trial design perspective, determining a clinically important benefit by relative vs. absolute risk reduction may influence the choice between early vs. late MACE as the study endpoint. G.C. has receieved research grant support to the Beth Israel Deaconess Medical Center, Harvard Medical School from Portola Pharmaceuticals, Bayer, Janssen Scientific Affairs, and CSL Beh-ring.

P.0817 Sociodemographic and lifestyle predictors of mental health adaptability during COVID-19 compulsory confinement: a longitudinal study

There is conflicting evidence for adverse outcomes after coronary artery bypass surgery (CABG) with prior percutaneous intervention (PCI). A literature search was performed from 1998 to 2017 and articles with primary or secondary outcomes of survival, major adverse cardiovascular events (MACE), and myocardial infarction in CABG patients with prior PCI were included. Forest plots were generated from odds ratios for survival, MACE, and myocardial infarction for unmatched and propensity-matched data. Heterogeneity between studies was assessed for all outcomes using I2. Funnel plots were generated for early survival, survival at 5 years, survival at >5 years, and MACE. Thirty-one studies were included over 18 years with 194,544 patients without PCI prior to CABG and 23,519 patients (12.09%) with prior PCI. Prior PCI did not adversely affect survival among the included studies (inverse rate ratio: 1.12, 95% confidence interval: 0.98–1.27, P = 0.110. MACE was significantly worse for those with prior PCI (odds ratio: 1.26, confidence interval: 1.02–1.55, P = 0.03). The relative risk of mortality associated with prior PCI has decreased significantly over the last 2 decades. Studies with higher percentage of prior PCI patients had higher relative mortalities. There was significant heterogeneity between studies for the treatment effects. PCI prior to CABG in recent times does not adversely affect survival despite adverse early and late MACE rates. However, high institutional rates of prior PCI may be associated with increasing mortality after CABG.

Factors Impacting on the Early Versus Late Major Adverse Cardiovascular Events Amongst Oncology Patients Receiving Non-Anthracycline Chemotherapy

Cardiovascular (CV) events following commencement of cancer treatment are becoming increasingly recognised. The extent to which baseline CV factors influence the onset of major adverse cardiovascular events (MACE) in patients treated with non-anthracycline chemotherapy is not well characterised. The aim of our study was to examine the association between baseline cardiovascular risk factors and early and late complications of non-anthracycline chemotherapy.

Long-term outcomes amongst adults with anatomic repair for transposition of the great arteries: Not as perfect as we would have hoped?

Most of the patients who underwent arterial switch operation (ASO) for D-transposition of the great arteries (D-TGA) reach adulthood. However, they may have residual lesions necessitating lifelong surveillance. We aimed to evaluate the long-term outcomes of a large number of contemporary ASO patients. We examined late major adverse cardiovascular events (MACE) in adult TGA patients (> 16 years) who underwent an ASO between 1980 and 2002 and continued their follow-up in 2 major tertiary ACHD centers. MACE were defined as death, re-intervention, myocardial ischemia, arrhythmia, stroke/transient ischemic attack, infective endocarditis and heart failure. Overall, 306 patients (67% male, mean age 25 ± 5years) were followed in adult life for a median of 8 years [IQR 6–13]. Seventy-three (23.8%) patients experience MACE, including 40 medical events and 60 reinterventions. MACE -free survival at 2, 5, and 10 years of follow-up in adulthood was 93.0%, 85.1%, 70.7%, respectively. Atrial arrhythmia was the most frequent cardiac event with an incidence of 3.8‰ patient-years, whereas the incidence of life-threatening ventricular tachyarrhythmia was 1.7‰. Coronary artery disease was diagnosed in 11 (3.5%) patients. The most frequent indication for cardiac intervention was right ventricular outflow tract obstruction ( n = 40/60, 66.7%) followed by coronary revascularisation procedure ( n = 11/60, 18.3%), Fig. 1 . On multivariate analysis, history of cardiac complications during infancy (HR 2.7, 95%CI:1.6–4.5, P < 0.01) and uncommon coronary patterns (HR for type B/C/D/E versus type A 1.7, 95%CI:1.0–2.9, P = 0.03) were independent predictors of MACE in adulthood. MACE are common in adult patients with ASO for TGA, particularly those with a history of cardiovascular complications during childhood and uncommon coronary pattern. Consequently, all patients with an anatomic repair for TGA merit life-long tertiary care.

Long-term outcomes amongst adults with anatomic repair for transposition of the great arteries: not as perfect as we would have hoped?

Abstract Background The arterial switch operation (ASO) has replaced atrial switch procedures for D-transposition of the great arteries (D-TGA), with 90% of patients now reaching adulthood. However, patients may have residual lesions and/or sequelae, some of which may remain unrecognized, necessitating lifelong specialist surveillance. We examined the cardiac outcomes of a large number of contemporary ASO patients under tertiary adult congenital heart disease (ACHD) care. Methods We examined late major adverse cardiovascular events (MACE) in adult TGA patients (&amp;gt;16 years) who underwent an ASO between 1981 and 2003 and continued their follow-up in 2 tertiary ACHD centers. MACE were defined as death, re-intervention, myocardial ischemia, arrhythmia, stroke/TIA, infective endocarditis and heart failure. Results Overall, 199 patients (66% male, mean age 27±5 years) were followed in adult life for a median of 10 years [IQR 7–15] and were included in this study. Overall survival during this period was 99.5% (95% confidence interval [CI]: 94.4%-99.8%). Sixty-two (31.2%) patients experience MACE, including 52 reinterventions. MACE and reintervention-free survival at 20, 30 and 35 years were 87.6%, 58.6%, 50.6% and 89.5%, 69.1, 61%, respectively. Atrial arrhythmia was the most frequent cardiac event with an incidence of 5.5 cases per 1000 patient-years, whereas incidence of ventricular tachycardia and sudden cardiac death was 1.8‰ and 0.9‰ patient-years, respectively. Coronary artery disease was diagnosed in 6 (3%) patients, of whom 4 had symptoms, 1 had ST depression on ECG at rest and 3 had abnormal wall motion on echocardiography. The most frequent indication for reoperation was right ventricular outflow tract obstruction (n=35/52, 63.7%), whereas left ventricular outflow tract (LVOT) re-interventions rate increased significantly during adulthood compared to childhood from 1% to 5%, p=0.03 (Figure 1). On multivariate analysis, history of cardiac complications during infancy (HR 2.3, 95% CI:1.3–4.0, p&amp;lt;0.01) and uncommon coronary patterns (HR for type A versus B/C/D/E 0.47, 95% CI:0.26–0.83, p&amp;lt;0.01) were independent predictors of MACE in adulthood. At the latest follow-up, 90.9% of patients were functional class I, left ventricular ejection fraction was 59.6±6.5% and peak oxygen uptake 71.1±24.9% predicted. At least moderate neoaortic regurgitation and aortic dilatation (≥40mm) were present in 8.0% and 35.2%, respectively, with more than mild pulmonary stenosis in 19.6%. Conclusion Adult patients with ASO for TGA have a low late mortality. However, MACE are common requiring reintervention, particularly for RVOT obstruction and neo-aortic valve dysfunction, the latter with rising rates during adulthood. Patients with cardiovascular complications during childhood are at the highest risk for MACE. All patients merit life-long tertiary care. Figure 1 Funding Acknowledgement Type of funding source: Public hospital(s). Main funding source(s): Assistance Publique des Hôpitaux de Paris

TCT-844 Very Late (>1 Year) Stent-Related Adverse Cardiovascular Events: Individual Patient Data and Network Meta-Analyses From 19 Randomized Clinical Trials

The majority of stent-related major adverse cardiovascular events (MACE) after percutaneous coronary intervention (PCI) are believed to occur within the first year. Very late (>1-year) stent-related MACE have not been well described. Individual patient data from 19 prospective, randomized metallic

Prior Percutaneous Coronary Interventions May Be Associated With Increased Mortality After Coronary Bypass Grafting: A Meta-Analysis

There is conflicting evidence for adverse outcomes after coronary artery bypass surgery (CABG) with prior percutaneous intervention (PCI). A literature search was performed from 1998 to 2017 and articles with primary or secondary outcomes of survival, major adverse cardiovascular events (MACE), and myocardial infarction in CABG patients with prior PCI were included. Forest plots were generated from odds ratios for survival, MACE, and myocardial infarction for unmatched and propensity-matched data. Heterogeneity between studies was assessed for all outcomes using I2. Funnel plots were generated for early survival, survival at 5 years, survival at >5 years, and MACE. Thirty-one studies were included over 18 years with 194,544 patients without PCI prior to CABG and 23,519 patients (12.09%) with prior PCI. Prior PCI did not adversely affect survival among the included studies (inverse rate ratio: 1.12, 95% confidence interval: 0.98-1.27, P = 0.110. MACE was significantly worse for those with prior PCI (odds ratio: 1.26, confidence interval: 1.02-1.55, P = 0.03). The relative risk of mortality associated with prior PCI has decreased significantly over the last 2 decades. Studies with higher percentage of prior PCI patients had higher relative mortalities. There was significant heterogeneity between studies for the treatment effects. PCI prior to CABG in recent times does not adversely affect survival despite adverse early and late MACE rates. However, high institutional rates of prior PCI may be associated with increasing mortality after CABG.

Is 3D Dobutamine stress echocardiography ready for prime time? Diagnostic and prognostic implications.

Compare the diagnostic accuracy and prognostic value of echo contrast enhanced 2D and 3D Dobutamine stress echocardiography (DSE). We included 718 patients indicated for DSE. All had standard 2D, and contrast enhanced left ventricular opacification (LVO) for 2D and 3D acquisitions at rest and peak stress. Chi-square test was done to assess relationship between DSE result and early revascularization. Kaplan-Meier plots with Logistic regression analysis predicted late major adverse cardiovascular events (MACE) at a maximum follow-up of 84 months. The mean age was 63 ± 13 years (61% males) and follow-up was obtained in 692/718 (96.4%) patients. Only 32% had excellent baseline image quality. The DSE was abnormal in 19.4% patients on 2D, in 17.1% on 2D-LVO and in 19.1% on 3D-LVO. Early revascularization was performed in, respectively, 32.8%, 45.8%, and in 48.5% of stress-positive 2D, 2D-LVO, and 3D-LVO studies. After excluding the 66 patients receiving early revascularization 68/626 (10.9%) had MACE at a maximum follow-up of 84 months. Kaplan-Meier plots showed that stress-positive 2D-LVO and 3D-LVO studies not receiving early revascularization when assessed separately and combined had significantly worse outcomes for MACE compared with stress-negative patients (OR 3.69; 95% CI: 1.54-8.87; P = 0.011, OR 4.54; 95% CI: 1.72-12.93; P = 0.008, and OR 7.07, 95% CI: 1.62-25.16; P = 0.001, respectively). Combined use of 2D- and 3D-LVO DSE is ready for prime time considering the feasibility, improved diagnostic accuracy and prognostic value.

Postoperative troponin release is associated with major adverse cardiovascular events in the first year after noncardiac surgery

IntroductionTroponin elevations after intermediate-to-high risk noncardiac surgery are common and can predict mortality. However, the prognostic value for early and late major adverse cardiovascular events (MACE) is less well investigated. The authors evaluated the relationship between postoperative troponin release and MACE in the first year after noncardiac surgery. MethodsThis observational cohort registry comprised data of patients aged ≥60 years undergoing intermediate-to-high risk noncardiac surgery between July 2012 and 2015, at the Erasmus University Medical Center, Rotterdam, the Netherlands. High-sensitivity troponin T was measured on day 1 to 3 after surgery. Peak troponin values were divided into four categories: <14 ng·L−1, 14–49 ng·L−1, 50–149 ng·L−1 and ≥150 ng·L−1. The primary endpoint MACE was defined as the occurrence of myocardial infarction, angina, revascularization therapy or cerebrovascular accident in the first year after surgery. The incidence of MACE and all-cause mortality was calculated using Kaplan-Meier estimates. Cox regression was used to estimate risks for both endpoints. ResultsIn total, 3085 patients were included for analyses and peak troponin elevation above 14 ng·L−1 was present in 1678 (54.4%) patients. The overall incidence for one-year MACE was 5.8% (3.4%, 6.1%, 10.4% and 40.6% per increasing troponin category) with adjusted HR (95% CI) 1.32 (0.85–2.06), 2.53 (1.42–4.53) and 10.24 (5.91–17.75) for the consecutive increasing categories. One-year mortality occurred in 14.6% and showed a similar stepwise increase with adjusted HR (95% CI) 1.25 (0.98–1.60), 2.39 (1.72–3.32) and 3.79 (2.60–5.54). ConclusionOur dataset demonstrates a graded relationship between postoperative troponin release and occurrence of MACE in the first year after intermediate-to-high risk noncardiac surgery.

Circulating Sulfatide, A Novel Biomarker for ST-Segment Elevation Myocardial Infarction.

Aims: ST-segment elevation myocardial infarction (STEMI) is an acute inflammatory and thrombotic disease due to coronary artery atherosclerotic lesions. Studies have established the correlation of serum sulfatides with inflammation, thrombogenesis, and atherosclerosis. We observed that serum sulfatides level significantly increased in STEMI patients. In this study, we try to identify the relationship of serum sulfatides level on clinical outcomes of patients in STEMI.Methods: Serum sulfatides level was monitored in 370 inpatients within 24 h of STEMI onset. On the basis of the level of serum sulfatides that was below 10 µmol/L in the normal population, the patients were divided into two groups with the median value of 15.2 µmol/L; low sulfatide group [serum sulfatides level ≤ 15.2 µmol/L (n = 200)] and high sulfatide group [serum sulfatides level > 15.2 µmol/L (n = 170)]. Patients' baseline characteristics, in-hospital outcomes, and late major adverse cardiovascular events (MACE) were analyzed. Independent incident for in-hospital death and late adverse events were modeled by multivariate logistic and Cox regression analysis.Results: Between the two groups, there were no differences in the angiographic characteristics, percutaneous coronary intervention (PCI) results, and in-hospital recovery. However, high serum sulfatides level is positively correlated with increased rate of in-hospital death (OR 0.971; 95% CI 0.926–0.990, p = 0.019). In addition, this group of patients has more cumulative incidences of target vessel revascularization (TVR) (23% vs. 8%, p < 0.05) and increased overall MACE (28% vs. 10%, p < 0.05). Cox regression analysis indicated that high serum sulfatides level contributes to TVR and overall MACE.Conclusions: Elevated serum sulfatides level positively correlate with in-hospital death and complications (TVR and MACE) in STEMI patients.

Posttreatment platelet reactivity on clopidogrel is associated with the risk of adverse events after off-pump coronary artery bypass

Dual antiplatelet therapy with aspirin and clopidogrel is currently recommended in off-pump coronary artery bypass (OPCAB). However, no data exist concerning platelet reactivity on clopidogrel after OPCAB. The aim of this study was to assess the relationship between platelet reactivity and late major adverse cardiovascular events (MACEs) after OPCAB. In this prospective, single-center, observational study, on-clopidogrel platelet reactivity was measured using a point-of-care assay (VerifyNow system; Accumetrics Inc, San Diego, CA) in 859 patients who underwent OPCAB with 1 or more vein grafts. The primary end point was late MACEs (30 days-1 year) including cardiac death, nonfatal myocardial infarction, and target vessel revascularization. Receiver operating characteristic curve analysis was used to estimate the cutoff value of P2Y12 reaction units (PRUs) for MACEs. The optimal cutoff value for posttreatment reactivity for the incidence of late MACEs was ≥188 PRU (area under the curve 0.72, 95% CI 0.68-0.75, P = .002). The incidence of late MACEs was significantly higher in the high platelet reactivity (HPR; ≥188 PRU) group than in the low platelet reactivity (<188 PRU) group (3.6% vs. 1.4%, P = .040). Kaplan-Meier analysis revealed 1-year MACE-free survival rates of 98.4% ± 0.5% and 95.9% ± 1.3% in the low platelet reactivity and HPR groups, respectively (P = .034). According to a Cox regression hazard model, HPR was an independent risk factor for late MACE-free survival (hazard ratio 3.51, 95% CI 1.27-9.69, P = .015). High residual platelet reactivity after clopidogrel administration is strongly associated with 1-year MACE-free survival. Routine measurement of platelet reactivity and thorough monitoring of patients with HPR after OPCAB are warranted.

Preoperative Estimated Glomerular Filtration Rate is an Independent Predictor of Late Cardiovascular Morbidity after Mitral Valve Surgery

Renal dysfunction affects outcomes of cardiac surgery, although its role in mitral valve operation has been limitedly documented. Two hundred and ten patients who underwent mitral valve operation between 2004 and 2011 were divided into 3 groups according to preoperative estimated glomerular filtration ratio (eGFR): group A (eGFR ≥60 ml/min/1.73 m(2), n = 102), group B (eGFR, 59-30 ml/min/1.73 m(2), n = 92) and group C (eGFR <30 ml/min/1.73 m(2), n = 16). Freedom from all-cause and cardiovascular death at 5 years was 77.2% and 93.0%, respectively. No significant differences existed between the 3 groups. In contrast, there was a significant difference in freedom from major adverse cardiovascular events (MACE) between groups (70.4%, 57.1%, and 42.8% in group A, B, and C, respectively; p = 0.008). By univariate and multivariate analysis, eGFR <60 ml/min/1.73 m(2) (HR: 1.92, 95% CI: 1.02-3.68, p = 0.044) and left ventricular ejection fraction <40% (HR: 2.69, 95% CI: 1.17-6.23, p = 0.02) were independent risk factors of MACE, although serum creatinine failed to represent an independent risk factor. Patients who underwent mitral valve surgery had acceptable perioperative and long-term survival, irrespective of preoperative renal function. However, eGFR <60 ml/min/1.73 m(2) was an independent predictor of late MACE.

Avaliação muito tardia do uso de stents farmacológicos para tratamento de pacientes com lesões em enxertos de veia safena: experiência de uma década do Registro DESIRE

INTRODUÇÃO: A intervenção coronária percutânea (ICP) em pontes de safena ainda representa um desafio à cardiologia intervencionista, pelas complicações agudas e pela escassez de dados referentes à efetividade tardia dos stents farmacológicos (SFs). MÉTODOS: Entre maio de 2002 e janeiro de 2013, pacientes submetidos a ICP com SF no Hospital do Coração foram incluídos no Registro DESIRE. Avaliamos os resultados de pacientes submetidos a ICP em pontes de safena (grupo 1), que foram comparados aos submetidos a ICP em vasos nativos (grupo 2). RESULTADOS: De um total de 4.655 pacientes, 311 foram incluídos no grupo 1 e 4.344, no grupo 2. O grupo 1 contou com pacientes mais idosos (68,4 ± 9,7 anos vs. 64 ± 11,2 anos; P < 0,01), com mais pacientes do sexo masculino (87,1% vs. 76,7%; P < 0,01) e com maior incidência de comorbidades. Angina instável foi a apresentação clínica mais frequente nesse grupo. Pacientes do grupo 1 receberam stents de maior calibre (3,18 ± 1,11 mm vs. 2,86 ± 0,43 mm; P < 0,01) e foram submetidos menos frequentemente a pré-dilatação (36,3% vs. 50,7%; P < 0,01) e a pós-dilatação (38,3% vs. 58,4%; P < 0,01). Apresentaram mais infarto agudo do miocárdio não-fatal na fase hospitalar (11,3% vs. 4,1%; P < 0,01) e mais eventos cardiovasculares adversos maiores na fase tardia (32,8% vs. 13,9%; P < 0,01), à custa de óbito cardíaco (7,7% vs. 3,2%; P = 0,02) e de revascularização da lesão-alvo (9% vs. 4,3%; P < 0,01). Trombose definitiva do stent foi mais frequente no grupo 1 (3,5% vs. 1%; P < 0,01). CONCLUSÕES: A despeito do inquestionável benefício dos SFs nos resultados tardios de ICP em pacientes complexos, o tratamento de pacientes com lesões em pontes de safena ainda permanece um desafio, com resultados agudos e tardios menos favoráveis que os de pacientes com lesões em vasos nativos.

Abstract 2535: The Adverse Long-Term Impact of Renal Impairment on Patients undergoing Percutaneous Coronary Intervention in the DES Era

Renal impairment (RI) is known to be associated with poor in-hospital outcomes following percutaneous coronary intervention (PCI) but its effect on outcomes beyond one year, particularly in the drug eluting stent (DES) era has not been reported. We undertook an observational study to determine the long-term impact of renal impairment on patients undergoing PCI at a large, tertiary cardiac referral centre. Baseline creatinine was available for 11,969 of the 15,012 consecutive patients undergoing PCI at our institution between April 2000 and Sept 2007. Patients were stratified into those with or without at least moderate RI, defined as a creatinine clearance &lt;60ml/min (CKD class ≤ 3). In-hospital mortality and morbidity were calculated for each cohort. Follow up data was obtained through linkage to a provincial registry. Kaplan-Meier analysis was performed and Cox multiple regression analysis was used to identify independent predictors of late mortality and MACE (major adverse cardiovascular events), and to examine the association between DES use and late outcomes in the presence or absence of RI. Of the 11,953 patients with available long-term follow-up, 3070 had RI (25.7%). In hospital mortality and MACE were significantly increased in those patients (3.34% vs 0.44%, p&lt;0.001, and 5.73% vs 2.2%, p&lt;0.001, respectively). At 7 year follow-up, survival and MACE-free survival were both reduced (64.5 ± 1.4% vs 89.4 ± 0.5%, p&lt;0.001, and 44.0 ± 1.4% vs 63.4 ± 0.8%, p&lt;0.001). RI was identified as an independent predictor of both late mortality and cardiovascular events (HR 2.2, p&lt;0.0001 and HR 1.4, p&lt;0.0001) but DES use was associated with a significant risk reduction for these events (HR 0.7, p&lt;0.0001). In patients with RI, DES use, rather than bare metal stents, was associated with a reduction in mortality (HR 0.83, CI 0.66 –1.0, p=0.1) and reduced subsequent CABG (HR 0.46, CI 0.22– 0.97, p=0.041) but had no effect on repeat PCI (p=0.63). In a large registry of “all-comers” for PCI, RI was an independent predictor of adverse late outcomes at 7 year follow-up. DES use however was associated with improved long-term outcomes in this high risk cohort.

Usefulness of 64-Slice Cardiac Computed Tomographic Angiography for Diagnosing Acute Coronary Syndromes and Predicting Clinical Outcome in Emergency Department Patients With Chest Pain of Uncertain Origin

Multidetector computed tomography (MDCT) has high diagnostic value for detecting or excluding coronary artery stenosis. We examined performance characteristics of MDCT for diagnosing or excluding an acute coronary syndrome in patients presenting to the emergency department (ED) with possible ischemic chest pain and examined relation to clinical outcome during a 15-month follow-up period. We prospectively studied 58 patients (56+/-10 years of age, 36% female) with chest pain possibly ischemic in origin and no new ECG changes or elevated biomarkers. The patients underwent 64-slice contrast-enhanced MDCT, which showed normal coronary vessels (no or trivial atheroma) in 15 patients, nonobstructive plaque in 20 (MDCT-negative patients), and obstructive coronary disease (> or = 50% luminal narrowing) in 23 (MDCT-positive group). By further investigation (new elevation of cardiac biomarkers, abnormal myocardial perfusion scintigraphy and/or invasive angiography), acute coronary syndrome was diagnosed in 20 of the 23 MDCT-positive patients (ED MDCT sensitivity 100% [20/20], specificity 92% [35/38], positive predictive value 87% [20/23], negative predictive value 100% [35/35]). During a 15-month follow-up period, no deaths or myocardial infarctions occurred in the 35 patients discharged from the ED after initial triage and MDCT findings. One patient underwent late percutaneous coronary intervention (late major adverse cardiovascular events rate, 2.8%). Overall, ED MDCT sensitivity for predicting major adverse cardiovascular events (death, myocardial infarction, or revascularization) during hospitalization and follow-up was 92% (12/13), specificity was 76% (34/45), positive predictive value was 52% (12/23), and negative predictive value was 97% (34/35). We found that 64-slice cardiac MDCT is a potentially valuable diagnostic tool in ED patients with chest pain of uncertain origin, providing early direct noninvasive visualization of coronary anatomy. ED MDCT had high positive predictive value for diagnosing acute coronary syndrome, whereas a negative MDCT study predicted a low rate of major adverse cardiovascular events and favorable outcome during follow-up.

Angioplastia primária via radial com doses aumentadas de tirofiban: uma técnica segura e efetiva

INTRODUÇÃO: O acesso transradial para a realização de angioplastia primária é eficaz e seguro, mesmo com utilização de um regime agressivo de anticoagulação e antiagregação. O objetivo dessa série histórica de casos é avaliar a segurança e a efetividade da angioplastia primária via radial associada à utilização de bolus com dose aumentada de tirofiban. MÉTODO: Foram avaliados, retrospectivamente, no período de janeiro de 2006 a abril de 2007, 73 pacientes submetidos à angioplastia primária, em nosso serviço, pelo acesso radial, com análise dos resultados hospitalares e tardios, com enfoque nas complicações hemorrágicas e vasculares. RESULTADOS: Obteve-se sucesso de 100% na utilização da via de acesso radial. Sucesso angiográfico ocorreu em 95,8% dos pacientes. A artéria coronária direita foi tratada em 50% dos casos. Tirofiban com bolus aumentado foi utilizado em 75% dos pacientes. Durante a fase hospitalar, houve três óbitos de causa cardíaca e nenhum caso de sangramento maior. Hematomas localizados ocorreram em 5,4% dos casos. No seguimento tardio (média de 7 meses), a taxa de mortalidade foi de 5,4%, sem nenhuma complicação relacionada ao sítio de punção arterial ou sangramento maior. CONCLUSÃO: No nosso serviço de cardiologia intervencionista, que utiliza a via radial sistematicamente, seu emprego na angioplastia primária é altamente eficaz e seguro, a despeito do uso de um regime de anticoagulação e antiagregação agressivos.

Excessive carotid in-stent neointimal formation predicts late cardiovascular events.

To examine if excessive in-stent neointimal formation causing a subcritical stenosis may indicate enhanced vascular reactivity in response to injury, thus predicting late cardiovascular events. One hundred consecutive patients (64 men; median age 71 years) with high-grade internal carotid artery stenoses (68 asymptomatic, 32 symptomatic) underwent carotid artery stenting (CAS). High-sensitivity C-reactive protein (hs-CRP) was measured before CAS. Patients were monitored with duplex ultrasound for excessive in-stent neointimal formation (flow-compromising lumen diameter reduction >/=50%), critical restenosis (>/=70%), or the occurrence of late major adverse cardiovascular events (MACE) defined as myocardial infarction (MI), stroke, and death occurring later than 30 days poststenting. Over a median 23-month follow-up, excessive neointimal formation was observed in 14 (14%) patients, restenosis in 2 (2%), and 30 late MACE in 25 [25%: 4 MIs, 2 ipsilateral strokes (in the patients with restenosis), 8 contralateral strokes, and 16 cardiovascular deaths]. Cumulative MACE-free survival rates at 6, 12, and 24 months were 92%, 84%, and 77%, respectively. Baseline hs-CRP levels were associated both with neointimal hyperplasia (p=0.024) and MACE (p=0.021). Patients with excessive neointimal formation exhibited a significantly increased adjusted risk for MACE (hazard ratio 3.56, p=0.010). Excessive in-stent neointimal formation after CAS indicates an increased risk for late MACE, potentially reflecting a state of exaggerated vascular reactivity in response to injury. Inflammation, which is associated both with neointimal hyperplasia and MACE, seems a common characteristic of different vascular pathologies.